mmim^^p^^ 


I 

; 

- 

■ 

■  * 

DOCUMENTS 
DEPT. 


nin  -Ti-j  itA 


REPORT 


of  the 


HEALTH  INSURANCE  COMMISSION 

of  the 


STATE  OF  ILLINOIS 


n 


» « , )  , 


MAY  1,   1919 


[Printed  by  authority  of  the  State  of  Illinois.] 


i6rf^3 


DOCOMENTa 
DEPT, 


MEMBERS  OF  HEALTH  INSURANCE  COMMISSION. 


William  Butterworth. 

Dr.  E.  B.  Coolley. 

Edxa  L.  Foley. 

Dr.  Alice  Hamilton. 

Mary  McExerxey. 

John  E.  Eaxsom. 

]\Iatthew  Woll. 

M.  J.  Wright. 

William  Be  ye.  Chairman. 


H.  A.  MiLLis,  Secretury. 


Springfield,  III. 
Illinois  State  Journal  Co.,  State  Printers 
•     1919 

17269—2500 


TABLE  OF  CONTENTS. 


PAGE. 

letter    of    Transmittal ' V 

PART    T.      SUMMARY    STATEMENT     OF     FACTS,     WITH    THE   COMMISSION'S 

-  FINDINGS  AND  RECOMMENDATIONS. 

Chapter  I.     The  Problem. 

1.  The  number  ill  at  a  given  time 4 

2.  The  sickness  experience  of  a  year 9 

3.  Disabling    sickness    of    wafe^e-earners 11 

4.  The    cost    of   sickness 15 

.'.  Sickness  and  changes  in  the  standard  of  living;  sickness  and  poverty..  19 

6.  Some    Illinois    vital    statistics ^ 22 

7.  Conditions  and  behaviour  causing  disease  and  death 27 

8.  Responsibility  for  sickness  and  premature  death 33 

9.  The  prevention  of  sickness  and  premature  death 3  3 

Chapter  II.     Combating  Disease  and  Conserving  Health. 

1.  State  legislation  designed  to  improve  conditions  and  to  conserve  health.    38 

2.  The    department    of    public    health 39 

0.  Local    health    administration 42 

4.  The    campaign    against    tuberculosis 49 

5.  The  campaign   against  venereal   disease 54 

6.  Maternity    care 57 

7.  Infant    welfare    work 65 

8.  Medical   care   of   school   children 71 

1>.  The    physician    in    industry 74 

Chapter  III.     The  Care  of  the  Sick. 

1 .  Medical    Treatment 77 

2.  Hospital    service    in    Illinois 83 

3.  Dispensaries     and     clinics 90 

4.  Nursing    care. 94 

Chapter  IV.     Existing  Health  Insurance. 

1.  Introduction 105 

2.  Establishment    funds 109 

3.  Trade   union    benefit    systems 115 

4.  Insurance    by    fraternal    orders , 118 

5.  Foreign    benefit    societies 124 

6.  The  health  and  accident  business  of  casualty  insurance  companies  and 

assessment    associations ...    126 

7.  Industrial    life    insurance .132 

8.  Group     insurance ^35^ 

9.  "Insurance  as  found  among  wage-earners  in  Chicago 141 

10.  The   existing   health   insurance   summarized 144 

Chapter  V.     The  Commission's  Findings  and  Recommendations 149 

,   1.  The  problem  of  sickness  and  non-industrial  accidents  stated 150 

/    2.  Illinois    vital     statistics 154 

/    3.  The  causes  of  and  responsibility  for  disease 155 

4.  Health  legislation  and  public  health  administration 156 

5.  The    tuberculosis    problem.  .  ." ' 158 

''.  The  problem  of  venereal  disease 159 

7.  Maternity  care   and   infant  welfare  work 160 

8.  Hospital    facilities 161 

j       9.  Public    health    nursing 162 

I    10.  Health    insurance 162 

I    11.  Occupational     disease 167 

112.  The     Con-nnission's     recommendations 167 

168 

i:.xlilbii:  2 — Biil  I'o^  investigation  of  conditions  causing  maternal  and  infant 

Tnf)Tt'^  lif  V-  ..174 


461^83 


CONTENTS— Concluded. 

PART    II.      REPORTS    OF    SPECIAT.    TXVESTIGATIOXS. 

PAGE 

I.  A  2>iuuy  of  Chicago  Wage-earning  Families — E.  W.  Burgess,   Ph.   D...  ...17{» 

IT    A  Study  of  the  Disability  Data  of  a  Selected  Group  of  Association. "<  in  the 

nited   States — H.   W.   Kuhn,    Ph.   D .  .31^: 

Hi.  Dispensaries  and  Clinics  in  Illinois — John   E.   Ransom :  ' ' 

IV.  Occupational   Diseases  in   Illinois — Dr.    Alice   Hamilton. 

V.  Health  of  Illinois  Coal  Miners — Dr.  E.  R.  Hayhurst 

^  1     Insurance     by     Casualty     Companies      and      Assessment      Associations — 

Prbf essor    W.    M.    DuCfus ^ 

VII.  Fraternal    Insurance — Professor   W.    M.    Duffus 

VIII.  Industrial   Life    Insurance — Professor   W.  .M.   Duffus 

IX.   Group  Life  and  Group  Disability  Insurance — Professor  W.   M.  Duffus .  .  .  .  -t 

X.   Foreign   Benefit   Societies  in   Chicago — Jakub   Horak; ' .! 

XI.  Establishment  Funds  in   Illinois — Professor  A.   E.   Suffern 

XII.  Trade  Union  Benefit   Systems — Professor  A.   E.    Suffern 

XIII    The  (Present   Status  of  Health  Work  in  the  Public   Schools  of  Illinois — 

Wi   G.   Reeder "*V: 

XIV.  Sickness  Insurance  in  Germany — Henry  J.  Harris.  Fh.  D 

XA^  The  British  Health  Insurance  System — Edith  Abbott,  Ph.   D b' 

XVI.   The   Health    Insurance    Movement    in    the    T'liit.  fl    States — Professor    .Tohr. 
R.     Commons 


CHAPTER  I.     THE  PROBLEM. 


THE  EXTENT^  COST,  CAUSES  AND  RESULTS  OF  SICKNESS  AND  DEATH  AMONG 

WAGE-EARNERS  AND  THEIR  FAMILIES.^ 

The  many  specific  questions  the  Commission  may  be  expected  to 
answer  as  a  result  of  its  investigations  and  thought  may  be  grouped  into 
five  general  ones,  viz :  ( 1 )  What  is  the  problem  of  sickness  and  death  ? 
(2)  What  is  being  done  to  control  and  prevent  disease  and  to  conserve 
health?  (3)  What  is  being  done  to  care  for  the  sick  and  physically  dis- 
abled? (4)  AVhat  is  being  done  to  compensate  for  loss  of  earnings  and 
to  meet  the  bills  caused  by  sickness  and  death?  and  (5)  What  more,  if 
anything,  can  and  should  be  done  to  meet  the  situation  as  foun^?  These 
questions  are  of  course  more  or  less  interrelated.  The  problem  is  closely 
connected  with  what  is  being  done  to  solve  it;  what  more,  if  anything, 
should  be  done  to  solve  it  depends  upon  existing  facilities  and  methods  for 
dealing  with  it  which  will  be  presented  in  a  subsequent  chapter  as  well 
as  upon  its  nature  and  extent  as  revealed  by  analysis  and  then  measured. 
But  while  the  general  questions  are  each  related  to  the  other  it  has 
seemed  advisable  to  set  them  out  in  five  sections  or  chapters,  each  of  which 
is  devoted  primarily  to  a  consideration  of  one  question. 

It  will  not  be  expected,  of  course,  that  the  data  here  used  by  the 
Commission  will  have  been  drawn  entirely  from  its  investigations  and 
hearings,  or  investigations  made  for  it.  They  are  drawn  from  what  are 
believed  to  be  acceptable  sources  for  the  purpose,  but  naturally  emphasis 
s  placed  upon  the  results  of  investigations  made  by  the  staff  or  by  the 
many  officials  and  others  who  have  cooperated  with  the  Commission,  and 
the  testimony  given  at  the  Commission's  informal  conferences  and  public 
hearings.  The  results  of  the  more  important  investigations  made  for 
the  Commission  are  set  out  in  Part  II  of  this  report  in  such  detail  as 
•space  limitations  permit. 

What,  then,  is  the  problem  of  sickness  and  death  among  wage-earners 
nd  their  families  in  Illinois?  This  question  is  partially  answered  by 
ata  relating  to  the  extent,  cost,  causes  and  results  of  sickness  and  death 
^mong  those  who  occupy  this  economic  position  in  the  community. 

First  of  all,  however,  comes  the  question  as  to  the  number  of  wage- 
■arners  and  their  dependents  to  be  considered  in  this  connection. 

The  population  of  Illinois  July  1,  1918,  as  estimated  by  the  Bureau 
of  the  Census,  was  6,317,783.  The  Bureau  of  the  Census  reports,  for 
he  year  1910,  that  40.7  per  cent  of  the  population  of  Illinois  were  gain- 
iully  occupied,  and  from  its  reports  for  that  year  it  has  been  determined 
that  in  excess  of  72  per  cent  of  those  gainfully  occupied  were  working 
for  wages  or  small  salaries. 

^  For  brevity  "sickness"  is  here  used  to  cover  iUness  and  non-industrial  accidents. 


I 


Applying  these  percentages  it  may  be  estimated  that  the  number  of 
wage-earners  (in  all  branches  of  employment)  in  Illinois,  for  the  year 
ending  July  1,  1918,  exceeded  1,850,000.  In  1910  the  number  of  de- 
pendents per  person  gainfully  occupied  was  about  1.46.  Applying  this 
ratio,  the  total  number  of  dependents  in  wage-earning  families  would  be 
in  1918  more  than  2,700,000.  Thus  the  wage-earners  and  their  families 
in  1918  may  be  estimated  in  round  numbers  at  4,600,000  in  a  total  popu- 
lation of  6,317,783.2 

In  setting  out  and  measuring  the  problem  of  illness,  it  will  be  well 
first  of  all  to  discuss  in  summary  fashion  (1)  the  number  ill  at  a  given 
time;    (2)    the  sickness  experience  of  a  year;    (3)    disabling  sickness.; 
among  wage-earners;  (4)  the  costs  of  illness;  (5)  sickness  and  standards? 
of  living,  poverty  and  dependency;   (6)    some  Illinois  vital  statistics; 
(7)  conditions  and  behavior  causing  illness;  (8)  responsibility  for  con-^ 
ditions  causing  illness;  and   (9)   the  extent  to  which  sickness  may  be 
prevented  and  disabling  defects  remedied. 

(1)   The  Number  til  at  a  Given  Time. 

The  number  ill  in  the  community  at  a  given  time  is  of  importance^ 
as  indicating  the  amount  of  medical  work  to  be  done  to  conserve  and 
restore  health,  increase  efficiency  and  prolong  life,  and  as  one  factor  in 
measuring  the  economic  loss  due  to  sickness. 

The  statement  has  become  current  that  on  a  given  day  about  3  per 
cent  of  the  population  are  sick.  Of  course  those  who  make  a  statement 
of  this  kind  are  not  unmindful  of  the  fact  that  the  number  of  sick  varies 
greatly  from  time  to  time,  and  that  the  number  will  depend  to  a  greatly' 
extent  upon  the  use  of  the  word  "sickness,"  and  especially  whether  it  is 
limited  to  disabling  sickness  or  is  used  more  inclusively. 

The  figure  mentioned  above  was  based  largely  upon  foreign  experi- 
ence. It  is  only  recently  that  statistics  of  our  own  derived  from  can- 
vasses and  medical  examinations  have  become  available.  Those  we  now 
have  would  indicate  that  the  percentage  for  disabling  sickness  is  rather 
less  and  that  for  all  sickness  very  much  greater  than  three.  The  more 
important  statistics  may  be  summarized. 

In  August  and  September,  1917,  the  Health  Department  of  Phila-  ^ 
delphia  made  a  survey  or  house  to  house  canvass  in  which  it  was  found 
that  of  12,019  persons  covered,  514  or  4.28  per  cent  were  sick  at  the  time. 
The  term  "sick"  was  evidently  rather  inclusively  defined  for  only  36.7 
per  cent  of  those  reported  as  sick  were  recorded  with  "disabling  sick- 
ness." A  survey  made  of  Kensington,  a  working-class  district  selected 
as  fairly  typical  of  working-class  districts  in  and  about  Philadelphia, 
showed  that  167  or  5.22  per  cent  of  the  3,198  persons  in  the  743  families, 
were  sick  at  the  time  the  canvass  was  made  in  the  early  spring  of  1918. 

A  careful  medical  census  or  canvass  of  the  members  of  1,455  fam- 
ilies in  Framingham,  Massachusetts,  taken  in  April,  1917,  showed  that 
6.2  per  cent  were  sick.     In  this  case  it  is  important  to  note,  however, 
that  the  agents  and  nurses  taking  the  census  "were  instructed  to  ascertain    ^ 
not  only  illnesses  creating  total  disability  but  minor  disabilities  as  well." 

»  The  occupational  figures  here  used  are  based  upon  the  Census  of  Occupations, 
1910. 


f- 


^The  original  interpretation  of  the  term  'illness'  covered  all  minor  and 
serious  affections  in  need  of  medical  or  dental  advice  or  treatment." 
When  "the  term  was  restricted  to  mean  a  sickness  involving  actual  com- 
plete disability  at  the  time/'  the  percentage  was  reduced  frorn  6.2  to  1.8.-^ 

In  these  investigations  cited,  the  surveys  were  not  only  local,  but 
partial  or  of  small  areas.  Much  more  significant  and  fairly  acceptable 
are  the  investigations  of  serious  cases  of  illness  made  during  the  years 
1915  to  1917  by  the  Metropolitan  Life  Insurance  Company. 

All  told  seven  surveys  have  been. made  by  the  Metropolitan.  The 
canvasses  were  made  by  the  agents  of  the  company,  usually  in  the  course 
of  their  regular  duties.  The  data  were  obtained  from  families  in  which 
the  company  had  one  or  more  policyholders ;  hence  nearly  all  of  those 
canvassed  were  of  the  wage-earning  group.  The  agents  were  instructed 
not  to  make  any  particular  selection  of  families  for  the  purpose  and  to 
include  every  member  of  each  family  canvassed.  Again,  the  agents 
were  asked  to  record  only  serious  cases  of  sickness ;  trivial  cases  were  not 
to  be  returned.  Moreover,  they  were  instructed  to  determine  whether 
the  sick  person  was  able  or  unable  to  work.*  The  place^  time  and  most 
general  results  of  the  several  surveys  are  best  shown  in  summarized  form, 
as  follows.^ 


Community. 


Date  of 
survey. 


Number  of- 

persons 
enumerated. 


Percentages. 


Sick. 


Unable  to 
work. 


Rochester,  N.  Y 

Trenton,  N.  J 

State  of  North  Carolina 

Boston,  Mass ." 

Chelsea  District,  New  York  City 

Cities  in  Pennsylvania  and  West  Virginia. 
Kansas  City,  Mo 


Average  for  the  seven  surveys. 


Sept.,    1915 
Oct.,      1915 


Apr., 
July, 


1916 
1916 


A.pr.,  1917 
Mar.,  1917 
Apr.,  1917 


34,490 
3,491 
66,007 
97,259 
24, 043 
374, 301 
34,267 


633,858 


2.31 
2.55 
2.85 
1.96 
1.48 
1.96 
2.52 


2.02 


1.92 
1.98 
2.29 
1.F0 
1.38 
1.85 
2.39 


1.83 


Possibly  the  winter  months  when  sickness  is  more  prevalent  were 
not  adequately  represented  in  these  surveys,  and  the  distribution  by  time 
of  year  is  therefore  not  ideal.  Any  under-statement  because  of  this 
would,  however,  likely  be  offset  by  the  inclusion  with  sickness  of  all 
cases  of  disability  due  to  accidents  and  injuries.  With  633,858  persons 
enumerated  by  agents  who  had  personal  knowledge  of  most  of  them  and 
who  needed  no  introduction  to  the  families  canvassed,  and  with  a  large 
number  of  industrial  centers  widely  scattered,  it  is  believed  that  the 
results  arrived  at  measure  fairly  accurately  the  relative  number  of  per- 
sons in  wage-earning  families  known  to  themselves  to  be  seriously  sick  at 
a  given  time? 

The  difficulties  and  expense  involved  in  making  a  wide  survey  of 
this  kind  in  Illinois  would  have  been  so  great  that  it  was  not  attempted. 

3  Framingham  Monograph  No.   2,   The  Sickness  Census,  p.   8. 

*  Sickness   Survey   of  Principal   Cities   in  Pennsylvania   and   West   Virginia,  by 
Lee  K.  Prankel  and  Louis  I.  Dublin,  p.  3. 

^  Compiled  from  the  several  published  reports  of  the  Metropolitan's  Community 
bickness  Surveys.     The  column  "unable  to  w^ork"  is  not  limited  to  wage-earners. 


6 


5^ 


■ 

Moreover,  it  was  believed  that  such  a  survey  carefully  made  would  only  ' 
confirm  the  results  obtained  by  the  Metropolitan,  since  the  death  rates, 
composition  of  the  population,  and  the  industries  of  Illinois  differ  little 
from  those  in  the  communities  canvassed.     Finally,  the  results  of  can- 
vasses to  ascertain  the  amount  of  admitted  sickness  are  after  all  of  lim- 
'ited  value.    Of  much  greater  value  would  be  findings  based  upon  exten- 
sive medical  examinations.   Such  examinations  are  indispensable  in  meas- 
uring the  problem  in  hand  when  looked  at  from  the  point  of  view  of  the 
amount  of  medical  work  which  might  be  done  to  conserve  and  restore  ■ 
health,  increase  efficiency  and  prolong  life.     Such  data  have  been  made 
available  by  a  medical  census  at  Framingham,  Massachusetts,  the  ex- 
amination of  men  for  induction  into  the  Army  and  Navy,  the  examin-  a 
ation  of  wage-earners  by  industrial  physicians,  and  the  examinations  •  • 
of  school  and  other  children. 

Framington  was  selected  as  a  typical  American  industrial  center 
of  suitable  size  for  the  study  of  tuberculosis,  and  incidentally  of  sickness 
in  general.  The  population  is  about  20,000,  In  1917  canvasses  were 
made  of  families  from  which  the  percentages  of  "admitted  sickness 
noted  above  were  obtained.  Two  "medical  examination  campaigns 
have  also  been  made — in  April  and  November,  1917.  All  told  4,473 
separate  individuals  from  1,783  families  were  carefully  examined  by 
physicians  brought  to  Framingham  for  that  purpose.  The  canvassers 
arranging  for  the  examinations  were  instructed  not  to  include  sick 
individuals  under  treatment  and  an  effort  was  made  to  get  a  fair  selection  'i 
by  nationality,  economic  condition  and  residence.  "Of  the  total  ex- 
amined, 77  per  cent  or  3,456  were  recorded  as  ill;"  1,017  were  normal. 
"Illness"  was  defined  so  as  to  include  diseases  or  defects  of  either  a 
serious  or  a  minor  character.  In  1,006  of  the  3.456  cases  the  trouble 
was  defective  teeth,  leaving  2,450  who  were  diseased.  If  the  diseases 
and  defects  are  divided  into  "minor  ills"  and  "serious  affections,"  the 
respective  numbers  were  2,343  and  1,113.«  Thus  some  25  per  cent  of 
the  total  examined  were  found  to  have  "serious  affections."  It  is  inter- 
esting to  note,  also,  that,  while  the  percentage  of  those  between  15  and 

•  The  "minor  ills"  and  "serious  affections"  were  as  follows : 

Minor  Ills. 

Defective  teeth    1  006 

Enlarged  tonsils 563 

Colds,  coryza,  etc 132 

Bronchial  pulmonary  affections    (undiagnosed) 265 

Glandular  system   277 

Miscellaneous  affections ............  '.  .  .  . .  [ ,  , .  .  .  \[[[  '  '//  '  iqO 

Total    —^J^ 

-,       .,,,.  Serious  Affections. 

Tonsilitis    •  .,„ 

Pharyngitis    *. .'.'. .,  ii 

Laryngitis    ^^^ 

Bronchitis     « .i^ 

Cardiac  signs   |§J 

Cardiovascular    ^i^ 

Cardiorenal    f*^ 

Renal  ' ■.■.■.■.;.■.■.■.■.•.■.■. H 

Vascular   ^° 

Tuberculosis    °^ 

Miscellaneous    .........[.. o qq 

Total     

From  Framingham  Monograph  No.  4,"  pp. '  ii-ig. 


44  years  of  age  returned  as  ill  was  somewhat  smaller  than  that  of  the 
entire  number  (71  per  cent  as  against  77),  the  percentage  of  serious 
aifections  among  them  was  26  as  against  25  in  the  entire  group.  These 
results,  briefly  stated,  are  of  great  value.  As  the  report  states,  "repre- 
sentative as  the  examination  groups  are  of  different  nationality,  economic 
and  geographic  sections  in  the  population,  it  is  safe  to  assume  that  the 
examination  work  indicates  the  prevalence  of  illness  in  a  normal  indus- 
trial American  community.""^ 

In  stating  and  measuring  the  problem  of  illness,  especially  from  the 
point  of  view  of  the  medical  work  which  might  be  done,  the  results  of 
the  examination  of  drafted  men  have  great  value.  As  yet  only  the  re- 
sults of  the  examinations  incidental  to  the  first  draft  have  been  pub- 
lished.^ The  men  examined,  it  will  be  recalled,  were  between  21  and 
31  years  of  age.  The  total  examined  was  2,510,706.^  Of  these,  730,756, 
or  29.11  per  cent,  were  rejected  by  the  local  boards.  A  small  percentage 
of  those  physically  examined  and  accepted  by  these ,  local  boards  were 
rejected  when  again  examined  by  the  surgeons  in  the  camps  to  which 
they  were  sent.  Of  an  estimated  393,384  of  such  men,  the  surgeons, 
it  is  estimated,  rejected  22,989  or  5.8  per  cent.  Combining  percentages 
for  men  rejected  by  the  local  boards  or  by  the  camp  surgeons,  about  35 
per  cent  were  found  to  be  unfit  for  service.  Of  course  the  number 
diseased  or  physically  defective  was  much  larger,  for  not  all  such  were 
unfit  for  service. 

The  various  grounds  for  rejection  have  been  shown  for  10,258  of 
the  total  rejected.  The  leading  causes  were  defects  of  eye  (21.68  per 
cent),  defects  of  teeth  (8.50  per  cent),  hernia  (7.47  per  cent),  defects  of 
hearing  (5.94  per  cent),  heart  disease (5.87  per  cent),  and  tuberculosis 
(5.37  per  cent).  Each  of  the  other  causes  assigned  accounted  for  less 
than  5  per  cent  of  the  rejections.^^ 

The  number  of  men  called  in  Illinois  and  examined  by  the  local 
boards  was  187,535.     Of  these,  48,444  or  25.83  per  cent,  were  rejected 

^  Framingham  Monograph  No.  4.  pp.  11-12. 

*  More  complete  data  will  become  available  about  the  first  of  February,  1919. 

^  The  data  here  used  are  to  be  found  in  the  Report  of  the  Provost  Marshal  Gen- 
eral to  the  Secretary  of  War  on  the  First  Draft  under  the  Selective  Service  Act,  1917. 
See,  especially,  pp.  44  to  47. 

^^  Causes  for  physical  rejections.  Number.     Per  cent. 

1.  Total  number  of  cases  of  physical  rejections  considered 10,258      

2.  Alcoholism  and  drug  habit 79  0.77 

3.  Physical  undevelopment    416  4.06 

4.  Teeth     ;...  871  8.50 

5.  Blood  vessels   191  1.86 

6-   Bones     304  2.96 

7.  Digestive  system   ; 82  .80 

8-  Ear 609  5.94 

9-  Eye 2,224  21.68 

10.  Jomts     346  3.37 

11.  Muscles    66  64 

U-  B-espiratory    '.'.'.'.'.'.'.['.'.['.'.'.'.'.'.'.'.'.  161  l!56 

1 7  §.,  '^  y  1 118  1.15 

}i-  ^^at  foot 375  3.65 

15.  Orenito-urmary   (nonvenereal)    142  1  39 

16.  Genito-urinary    (venereal)    '  438  427 

17.  Heart  disease    ^ 602  5.87 

18.  Hernia 766  7  47 

19.  Mentally  deficient '.  .■.■.".■.■.■.';.'.'.:: :;:;;::::;      465        4;53 

oV"  ^i^rvous  disorder  (general  and  local) 387  3  77 

^1.   Tuberculosis    551  5  37 

22.  Underweight     ..........]....[..[[.  163  1^59 

23.  Ill-defined  or  not  specified 93  91 

24.  Not  stated    .*.'!!.*!.'.'.*.".'!.'  i  .'!.'.".'.' ."  809  7.'89 


8 

as  physically  unfit.  This  percentage,  it  is  interesting  to  note,  was  3.SB 
points  less  than  the  average  for  the  entire  country.  In  general,  it  may 
be  said  that  the  largest  percentage  of  rejections  occurred  in  the  older 

industrial  states.^ ^ 

It  would  be  interesting  to  know  how  these  results  would  compare 
with  the  results  of  a  similiar  examination  of  the  much  larger  number 
of  wage-earners  in  "the  industrial  army."  Hoping  to  secure  data  of 
value  the  Commission  has  sought  to  secure  the  results  of  physical  ex- 
aminations of  wage-earners  by  industrial  physicians  connected  with  large 
establishments  in  different  industries  of  importance  in  Illinois.  The 
effort  has  not  been  as  successful  as  had  been  hoped.  Accurate  records 
are  the  exception  and  not  the  rule  and  these  records  and  also  the 
thoroughness  and  nature  of  the  examinations  vary  greatly  from  one 
establishment  to  another.  The  examination  of  applicants  for  work  and 
of  employees  and  the  record-keeping  are  far  from  being  standardized 
and  made  uniform.  Most  frequently  only  causes  of  rejection  are  recorded. 
Moreover,  labor  policies  and  the  kind  of  labor  needed  differ  so  greatly 
from  one  establishment  to  another  that  the  rejection  of  applicants  does 
not  indicate  any  definite  dividing  line  between  serious  and  minor  ail- 
ments found.  Under  the  circumstances  it  would  not  be  helpful  to  do 
more  than  summarize  the  findings  in  eight  possibly  typical  cases  where 
the  results  may  be  combined. 

The  industrial  physicians  connected  with  these  eight  establish- 
ments in  1917  examined  69,171  male  applicants  for  work.  They  found 
32,866  or  33.1  per  cent  of  these  diseased  or  defective,  and  rejected 
13,119  or  57.4  per  cent  of  them  as  unfit  for  employment. ^^  The  re- 
jected constituted  19.0  per  cent  of  those  examined.  Among  the  22,866 
were  1,406  with  hernias,  205  with  tuberculosis,  342  with  kidney  trouble, 
1,184  with  high  blood  pressure,  1,663  with  defective  vision,  564  with 
bad  teeth,  and  19  with  contagious  diseases.  In  using  these  statistics,  it 
should  be  remembered  that  they  have  been  obtained  from  the  examin- 
ation of  men  not  too  ill  or  too  defective  to  apply  for  work.  The  data 
are  of  course  partial  and  drawn  from  too  few  sources.  ^N'evertheless  they 
serve  the  purpose  of  indicating  that  there  is  much  to  be  considered  that 
is  not  disabling  sickness.  To  what  extent  the  efficiency  of  these  men 
is  affected  by  the  disease  or  physical  defect  found  cannot  be  determined. 

Many  of  the  diseases  and  physical  defects  found  in  the  examinations 
of  draftees  and  applicants  for  work  have  persisted  from  childhood.  At 
any  rate,  the  examination  of  school  children  shows  that  a  very  large 
percentage  of  them  are  in  need  of  medical  or  dental  care.  In  1915  the 
Division  of  School  Hygiene  of  the  Chicago  Department  of  Health  made 
physical  examinations  of  children  in  a  large  number  of  the  schools. 
While  it  cannot  be  said  that  these  schools  were  typical  of  the  entire  num- 
ber, the  results  of  the  examinations  show  that  disease  and  defects  of 
importance  at  the  time  and  in  connection  with  the -efficiency  of  the  next 
generation  of  those  who  work  are  very  numerous.     All  told  79,383  were 

"  See  Provost  Marshal's  Report,  cited  above,  p.  83. 

"  The  percentages  of  applicants  rejected  because  diseased  or  defective  varied  in 
these  eight  cases  from  three-tenths  of  1  per  cent  as  a  minimum  to  54.1  per  cent  as  a 
maximum. 


examined.  Of  this  number  37,356,  or  47.1  per  cent,  were  found  to  be 
defective,  and  32,860  were  advised  to  seek  treatment.  A  tabulation  of 
the  defects  for  35,166  of  these  pupils  showed, the  following:  Malnu- 
trition, 804;  anaemia,  2,639;  enlarged  glands,  7,970;  goitre,  1,556; 
nervous  diseases,  340;  cardiac  diseases,  414;  pulmonary  diseases,  68; 
skin  diseases,  701;  orthopedic  defects,  171;  rickets,  372;  defective  vision, 
7,837;  other  diseases  of  the  eye,  1,076;  defective  hearing,  663;  dis- 
charging ear,  372;  defective  nasal  breathing,  2,603;  defective  palate, 
971;  defective  teeth,  22,711;  hypertrophied  tonsils,  11,777;  adenoids, 
4,489;  tonsils  and  adenoids,  4,350.^^ 

Not  all  of  the  above  diseases  and  defects  could  be  remedied  or  im- 
proved by  treatment.  Yet  the  fact  that,  of  the  37,356  found  to  be  de- 
fective, 32,860  were  advised  to  seek  treatment  is  very  significant. 

These  details  relating  to  Chicago  school  children  are  presented  be- 
cause thej^  are  not  untypical  of  what  will  be  found  in  almost  any  com- 
munity. In  rural  communities,  where  unlike  an  industrial  community, 
only  a  minority  of  the  pupils  are  from  wage-earning  families,  the  relative 
number  found  to  be  defective  has  been  shown  to  be  larger  than  in  cities. 
The  Committee  on  Health  Problems  of  the  National  Council  of  Edu- 
cation has  made  a  very  careful  estimate  of  the  percentage  of  physically 
defective  who  are  likely  to  be  found  in  any  community.  The  Com- 
mittee's estimates,  based  upon  a  large  body  of  data,  and  showing  results 
similar  to  those  found  in  Chicago,  are  as  follows: 


Defects. 

Percentages  with  each 
specified  defect. 

Urban. 

Rural. 

Teeth  defects „ 

33.5 

16.4 

12.0 

13.4 

1.3 

7.6 

2.7 

2.1 

.8 

1.5 

.3 

.4 

.2 

49.0 

Tonsils 

28.1 

Adenoids 

23.4 

Eve  defects 

21.0 

Ear  defects 

4   7 

Malnutrition 

16.  0 

Enlarged  glands 

6.4 

Breathing  defects 

4  2 

Spinal  curvature 

3.5 

Anaemia 

1.6 

Lung  disease 

1,2 

Heart  disease 

8 

Mental  defects. . 

-.8 

\. 

The  data  presented  are  sufficient  to  show  that  at  a  given  time  the 
percentage  of  persons  with  disabling  sickness  is  less  than  three,  that  of 
persons  diseased  or  defective  'is  very  much  greater  than  three — the 
figure  which  has  come  to  be  so  frequently  used  in  this  connection. 

(2)   I'he  Sickness  Experience  of  a  Year. 

While  it  is  interesting  and  important  for  the  reasons  stated  above 
to  know  how  many  of  a  working-class  group  are  ill  or  physically  defective 
at  a  given  time,  it  is  very  much  more  important  to  know  how  many  are 
disabled  by  sickness  in  the  course  of  a  normal  year,  how  long  they  are 

"For  an  account  of  the  work  of  the  Division  of  School  Hygiene,   see  Part  II 
of  this  report,  Special  Report  XIII. 


10     • 

disabled,  what  is  the  nature  of  the  sickness,  whether  the  wage-earner, 
housewife  or  other  member  of  the  family  is  ill,  how  much  time  and  wages 
are  lost  because  of  the  disability,  how  much  is  paid  out  directly  for  care 
and  medical  treatment,  afid  how  much  economic  strain  is  involved.  Un- 
fortunately few  investigations  extending  over  a  year  have  been  made  of 
wage-earning  families  as  a  group,  and  the  investigations  made  by  the 
Commisson  of  necessity  have  been  limited  to  residents  of  Chicago. 

Reference  has  been  made  to  the  survey  of  the  Kensington  district 
in  Philadelphia.  A  preliminary  statement  of  the  results  is  to  the  effect 
that  of  743  families  investigated,  all  but  12.4  per  cent  had  had  one  or 
more  cases  of  sickness  in  the  course  of  the  preceding  twelve  months. 
One  hundred  seventy-five  families  had  had  one  case  each;  173,  two  cases; 
162,  three  or  four  cases;  126,  five  or  more,  and,  of  these,  26  had  had  ten 
or  more  each.  Though  it  is  stated  that  many  of  the  minor  illnesses 
were  overlooked,  1,989  or  52.2  per  cent  of  the  3,198  persons  in  the 
families  canvassed  were  found  to  have  suffered  from  cases  of  serious  or 
minor  illness  in  the  course  of  the  preceding  twelve  months. 

In  order  that  it  might  obtain  as  accurate  information  as  possible 
with  reference  to  the  various  aspects  of  the  problem  presented,  the  Com- 
mission has  had  an  intensive  study  made  of  all  families,  wage-earning 
and  non-wage-earning,  in  forty-one  blocks  located  in  working-class  dis- 
tricts in  Chicago.  The  blocks  were  selected  with  care  so  that  they  would 
be  as  nearly  typical  as  possible  of  wage-earning  families  in  respect  to 
race,  industries  in  which  they  were  engaged,  and  the  degree  of  skill  of 
the  normal  breadwinner,  and  were  taken  from  most  parts  of  the  city. 
The  studies  of  a  few  other  blocks  were  left  incomplete,  but  inasmuch  as 
the  families  were  taken  in  order  as  they  were  reached  by  the  investigators 
and  there  was,  therefore,  no  selection,  the  schedules  have  been  combined 
"with  those  obtained  from  the  blocks  studied  completely.  All  told,  ex- 
tensive and  uniform  schedules  were  obtained  for  3,048  families  with  a 
total  of  12,450  persons. 

The  investigators,  who  were  carefully  selected  and  who  for  the 
greater  number  were  experienced  in  work  of  this  kind,  were  instructed 
to  secure  a  record  of  all  cases  of  serious  sickness  during  the  preceding 
twelve  months  for  each  member  of  the  family.  Minor  illnesses  were  not 
to  be  returned,  and,  if  returned,  have  been  cancelled  in  editing.  They 
were  instructed  specifically  to  enter  only  serious  chronic  illnesses  and 
such  acute  temporary  cases  as  caused  disability  for  work  on  the  part  of 
wage-earners  for  at  least  a  week,  or  the  confinement  of  others  to  the 
house  or  bed  for  the  same  length  of  time.  Exceptions  were  made,  how- 
ever, in  the  case  of  serious  shorter  illnesses,  as,  for  example,  bad  tonsils 
requiring  removal,  and  in  other  cases  where  a  physician  had  been  called.^* 

While  the  data  obtained  by  the  investigators  were  for  only  3,048 
families  residing  in  something  more  than  forty  blocks  in  Chicago,  it  is 
believed  that  they  indicate  fairly  accurately  how  much  disabling  sick- 
ness of  a  serious  nature  may  be  expected  in  a  normal  year.  The  twelve 
months  covered  were  about  normal  in  Chicago's  experience    (as  indi- 

"  The  detailed  results  of  this  investigation  are  set  forth  by  Prof.  E.  W   Burgess 
in  Special  Report  I,  in  Part  II  of  this  report.     Only  a  concise  summary  of  the  sick- 
ness experience  is  presented  here. 


11 

cated  by  the  normal  death  rate  for  that  period),  the  families  were  repre- 
sentative and  sufficiently  numerous,  the  investigations  were  carefully 
made,  and  sickness  among  these  families  should  not  differ  materially 
from  sickness  among  wage-earning  families  in  the  normal  industrial 
community. 

The  investigations  made  in  Chicago  showed  that  2,005  or  65.8  per 
cent  of  the  3,048  families^^  residing  in  the  blocks  studied,  had  had  one 
or  more  cases  of  serious  illness  (as  defined  above)  during  the  twelve 
months.  Of  the  12,450  members  of  these  families,  3,450,  or  27.7  per 
cent  of  the  entire  number  included  in  the  study  had  been  seriously  sick. 
In  571  families  the  sickness  was  confined  to  those  gainfully  occupied  as 
wage-earners  or  otherwise.  In  543  families  there  was  sickness  of  those 
gainfully  occupied  and  of  dependent  members  of  the  families.  In  the 
remaining  891  families  the  sickness  was  not  that  of  a  wage-earner. 
Putting  the  matter  in  a  different  way,  the  working  time  and  income  of 
one  or  more  persons  gainfully  occupied  in  1,114  of  3,048  families  had 
been  reduced  by  reason  of  sickness;  in  543  of  these  cases  sickness  of 
others  had  added  to  the  bills;  while  in  891  families  sickness  had  not 
caused  a  direct  loss  of  income  for  as  much  as  a  week  but  may  have  added 
to  the  bills.  The  duration  of  illness,  the  loss  of  income,  and  the  direct 
outlays  for  medical  and  other  care  are  presented  below  in  sections  (3) 
and  (4). 

(3)   Disahling  Sickness  of  Wage-earners. 

Unusual  importance  attaches  to  the  sickness  of  wage-earners  be- 
cause their  disability  involves  loss  of  wages  as  well  as  direct  outlays  for 
medical  care.  Impairment  of  income  by  reason  of  sickness  may  prove 
more  serious  than  unemployment  because  of  the  enlarged  bills  which 
must  be  met. 

A  finding  of  the  Commission  on  Industrial  Relations  with  refer- 
ence to  the  amount  of  working  time  lost  because  of  sickness  is  frequently 
quoted.  In  its  final  report  the  statement  is  made  that  "each  of  the 
thirty-odd  million  wage-earners  in  the  United  States  loses  an  average 
of  nine  days  a  year  through  sickness."^®  The  data  obtained  from  our 
various  investigations  warrant  the  conclusion  that  this  is  only  a  slight 
over-statement  of  the  average  time  lost. 

There  were  4,474  wage-earners  in  the  blocks  covered  by  the  Com- 
mission's investigations  in  Chicago.  Of  these,  1,222  were  returned  as 
having  been  seriously  sick  as  defined  above,  but  only  937  (20.9  per 
cent  of  the  entire  number)  lost  a  week  or  more  during  the  year  because 
of  sickness.  The  total  number  of  weeks  lost  by  901  reporting  in  full 
was  6,632.  This  was  an  average  of  7.35  weeks  for  each  wage-earner 
sick. 

These  data  are  few  and  have  limited  value  because  they  were  set 
down  in  weeks  and  were  obtained  from  the  families  and  not  from 
accurate  records.  What  is  needed  is  accurate  records  of  every  day  lost 
because  of  sickness  during  an  entire  year  by  the  wage-earners  in  repre- 
sentative groups.     The   agents  have  searched  for  records  approaching 

^5  These  include  340  families  where  the  head  of  the  familv  was  not  a  wage-earner. 
"  Commission  on  Industrial  Relations,  Final  Report,  p.  202.  * 


12  ^ 

this  ideal  but  with  little  success.  No  trustworthy  records  have  been 
found  in  Illinois  except  those  incidental  to  the  payment  of  sick  benefits 
and  these  never  give  a  complete  account  of  disabling  sickness.  Most  of 
the  organizations  paying  sick  benefits  to  wage-earners  keep  no  records 
except  of  the  days  for  which  benefits  are  paid.  Almost  always  there  is 
a  waiting  period  so  that  many,  and  not  infrequently  a  majority,  of  the 
cases  of  shorter  duration  are  not  recorded  at  all.  Again,  compensation 
is  limited  to  a  certain  period  of  time,  most  frequently  13  weeks.  The 
full  record  of  the  longer  cases  is  not  made.  Perhaps  no  compensation 
is  given  in  chronic  cases  or  for  venereal  diseases  or  for  sickness  due  to 
intemperance.  Perhaps  the  membership  of  the  organization  is  selected 
by  medical  examination  of  applicants  for  work  or  by  medical  examin- 
ation for  admission  to  membership.  And,  finally,  if  use  is  made  of  the 
records  of  establishment  funds,  it  is  likely  that  the  sickness  rate  obtained 
is  too  favorable  for  establishments  as  a  whole  because  most  of  the  firms 
concerned  give  more  than  the  usual  attention  to  sanitation  and  other 
things  reducing  the  amount  of  sickness. 

In  its  study  of  establishment  funds  the  Commission  secured  as 
complete  data  as  possible  for  their  sickness  experience.  Three  of  the 
largest  of  these  with  134,274  members  and  paying  benefits  where  dis- 
ability lasted  for  more  than  6  days,  paid  benefits  to  40,157  or  29.9  per 
cent  of  the  combined  membership  in  1917.  The  total  days  of  disability 
in  these  compensated  cases  was  1,189,179,  or  an  average  of  29.6  days 
per  case.  The  total  da3^s  "of  disability  as  given  would  average  8.9  days 
for  the  entire  membership.  Thirty-three  smaller  funds  with  66,854 
members  and  paying  benefits  where  disability  lasted  more  than  7  days, 
paid  benefits  in  1917  to  10,629,  or  15.9  per  cent  of  the  membership.  The 
total  days  of  disability  in  these  conipensated  cases  was  343,229  or  an 
average  of  32.3  days  per  case.  The  total  days  of  disability  as  given 
would  average  5.1  days  for  the  entire  membership.  Data  were  obtained 
covering  the  experience  of  other  funds  which  began  payments  with  the 
first,  third  or  fourteenth  day,  but  the  number  of  members  in  these  as 
grouped  are  too  small  to  have  any  particular  significance. 

This  Commission  has  cooperated  with  the  Commissions  in  Ohio, 
Pennsylvania,  and  Connecticut  in  an  effort  to  secure  as  large  a  body 
of  data  as  possible  from  representative  establishments  and  labor  organ- 
izations. The  data  are  of  unusual  interest  because  they  are  drawn  from 
the  largest  number  of  wage-earners  thus  far  studied.  The  results  have 
been  combined  by  Professor  Kuhn  of  Ohio  State  University,  and  are 
presented  in  Part  II  of  this  report.^^  Taking  nine  comparable  benefit 
associations  with  663,163  wage-earners  exposed,  131,921  or  19.9  per 
cent  were  compensated  for  disabilities  caused  by  sickness  or  non-indus- 
trial accident  and  lasting  for  8  or  more  working  days.  The  total  days 
of  disability  in  these  cases,  with  any  excess  over  189  in  any  case  not  in- 
cluded, was  3,610,536,  or  an  average  of  27.4  days  per  case.  Another 
combination  of  data,  somewhat  larger,i«shows  that  about  three  per  cent 
of  the  cases  lasting  more  than  8  days  last  longer  than  189  davs  and  that 


"  See  Part  II,  Special  Report  II. 

"See  Tables  VI  and  VII  of  the  study  cited  above. 


13 

the  total  days  of  disability  in  the  course  of  the  year  is  increased  by 
about  16  per  cent  by  that  fact.  Thus  the  total  days  of  disability  during 
the  twelve  months  for  the  131,921  disabled  for  8  days  or  more  was 
4,335,388.  This  spread  over  the  entire  663,163  exposed  would  give  an 
average  of  6.54  days  each,  disabilities  lasting  not  more  than  7  days  not 
being  reckoned  in. 

While  these  data  indicate  something  of  the  loss  due  to  sickness  and 
non-industrial  accident,  they  are  not  presented  and  cannot  be  accepted 
as  an  accurate  measure  of  disabling  illness  among  wage-earners  as  a 
whole.  Even  where  to  the  time  compensated,  the  time  covered  by  the 
waiting  period  and  that  extending  beyond  the  period  covered  by  benefits 
have  been  added,  an  understatement  is  involved  for  a  number  of  reasons. 
In  many  cases  there  is  a  selective  process  eliminating  those  who  involve 
most  risk  of  sickness;  sickness  of  shorter  duration  than  the  waiting 
period  is  not  included;  in  most  cases  disabilities  due  to  certain  kinds  of 
disease  or  intemperance  are  not  compensated  and  are,  therefore,  not  re- 
corded; and  the  maintenance  of  this  benefit  plan  for  which  the  data 
have  been  drawn  are  frequently  accompanied  by  a  health  program  pre- 
venting some  disabling-  sickness  which  would  otherwise  occur.  The 
figures  presented  understate  the  number  sick  in  the  course  of  the  year 
and  the  amount  of  time  lost.  How  much  understatement  is  involved 
is  not  known  but  it  is  by  no  means  slight. 

The  Bureau  of  Labor  Statistics  has  recently  completed  a  statistical 
analysis  of  the  Workmen's  Sick  and  Death  Benefit  of  New  York,  with 
an  average  of  36,972  members  covered  by  the  study  for  the  five  years 
1912  to  1916.^^  The  members  are  employed  in  many  occupations  in  a 
large  number  of  industries.  This  valuable  study  shows  that  disabilities 
of  16.8  of  those  exposed,  caused  by  sickness^  non-industrial  accident,  or 
industrial  accident,  and  lasting  8  days  or  more,  any  excess  over  189  days 
not  included,  averaged  6.3  days  for  the  entire  membership.  Benefits 
are,  however,  paid  from  the  first  day  of  disability.  The  data  show  that 
compensated  disabilities  lasting  not  more  than  7  days  averaged  approx- 
imately one-third  of  a  day  per  member.  This  does  not,  however,  show 
the  true  average.  The  disabilities  of  shorter  duration  were  not  fully 
recorded  for  the  number  compensated  increased  from  271  for  1  day 
to  2089  for  5  days. 

The  partial  evidence  available,  and  it  cannot  be  regarded  as  entirely 
representative,  indicates  the  conclusion  that  about  20  per  cent  will  be 
disabled  for  a  week  or  more  because  of  sickness  and  non-industrial 
accident  and  that  the  workmen  collectively  will  lose  in  the  course  of 
the  year  between  8  and  9  days  because  of  such  disabilities. 

Only  the  smaller  part  of  the  problem  of  sickness  among  the  wage- 
earners  is  indicated  by  such  a  statement  as  "each  of  the  thirty-odd 
million  wage-earners  in  the  United  States  loses  an  average  of  nine 
days  a  year  through  sickness."  If  every  wage-earner  were  disabled  by 
sickness  for  just  nine  days  each  year  it  would  not  be  a  serious  matter. 
The  most  important  fact  about  it  from  an  economic  point  of  view  is  that 

"  For  the  tabulated  results,  see  Part  II  of  this  report,  Special  Report  II.  The 
Commission  is  indebted  to  the  Commissioner  of  the  Bureau  for  these  data  in  advance 
of  publication  by  him. 


14 

only  a  fraction  of  any  representative  group  is  sick  in  a  given  year,  and 
that  some  of  these  are  disabled  for  such  a  short  period  of  time  that  it  is 
of  little  consequence,  while  others  may  be  sick  for  such  a  long  time  that 
an  acute  problem  is  connected  with  lost  wages  and  enlarged  bills.  In 
order  to  get  a  proper  view  of  the  problem  the  duration  of  sickness  as 
it  varies  from  the  average  must  be  studied.  This  has  been  done  in  the 
cooperative  way  indicated  above.  The  results  may  be  regarded  as  the 
beginning  of  an  American  experience  table  applicable  in  Illinois. 

As  already  stated,  the  Ohio,  Pennsylvania,  Connecticut  and  Illi- 
nois'commissions  have  studied  a  large  number  of  groups.  The  experi- 
ence of  the  benefit  associations  indicates  that  of  those  disabled  for  more 
than  7  days,  65  per  cent  will  be  sick  for  less  than  four  weeks;  19  per 
cent  from  four  to  eight  weeks;  7  per  cent  from  eight  to  twelve  weeks; 
6  per  cent  from  twelve  to  twenty-seven  weeks ;  3  per  cent  for  more  than 
six  months  and  1.29  per  cent  over  one  year.^^ 

It  is  recognized  of  course  that  sickness  data  should  be  shown  by  sex, 
age,  occupation,  and  specific  cause  of  disability.  Few  of  the  records 
used  have  made  this  possible.  This  Commission  has,  however,  been  able 
to  show  the  duration  of  disability  by  disease  for  twenty  manufacturing 
establishments,  an  office  force  and  a  sales  force.  The  results,  grouped 
into  uneven  periods,  are  shown  in  the  following  table. 


Total 

of 
cases. 

Number  of  cases  by  disease  and  duration  (in  days). 

Cause  of  disability. 

7-12 

13-18 

19-24 

25-30 

31-49 

50-77 

78-100 

101-150 

151-180 

Over  180 

Abscess,  infections,  in- 
flamai  ions 

605 

236 

132 

1,225 

23 

871 

1,124 

122 

106 

32 

55 

180 

1,281 

867 

146 

31 

77 
1,147 

303 
19 
30 

419 

476 

667 

12 

6 

17 

9 

10 

460 

365 

1 

16 
368 

132 
23 
32 

271 
2 

170 

274 

11 

9 

11 

7 

24 

250 

179 

i 

16 
215 

50 

29 

10 

157 

6 

83 

71 
9 
9 
4 
7 

28 
122 

72 
2 
3 

11 
105 

32 
21 
11 
80 
1 

40 

38 

8 

20 

64 

98 

15 

171 

2 

71 
47 
18 
42 

10 
17 
13 

45 

1 

16 
12 
10 
11 

4 
14 

6 
24 

3 

3 
7 

•2 

5 
10 

4 
22 

7 

>     3 

15 

2 

2 
2 
2 

1 
1 

2 

3 

3 

ADDondicitis. 

3 

B  adder,  kidney 

Bronchitis,  pleurisy  .. 
Cancer  

11 
33 

7 

Eye,    ear,    nose    and 
throat 

.i; 

OrlDDe.  colds 

3 

Heart 

2fi 

llcniia 

3 

Measles 

Kptiliiiti^    

5 

23 

81 

59 

2 

3 

7 
68 

9 
70 
178 
98 
10 
16 

12 
130 

4 
9 
55 
29 
7 
3 

5 
34 

3 

6 

34 

14 

2 

120 

2 

7 

30 

15 

11 

4 

3 

27 

4 

i4 

7 
14 

7 

5 

3 

37 

29 

89 

1 

5 

74 

Pti.               ;v 

illi«-uiMm  isni ......... 

Stomach,  intestines. . . 
Tuberculosis 

Typhoid ; 

Varicose    veins    and 
ulcers 

Miscellaneous 

Total  diseases 

Off  duty  accidents 

8,243 
1,630 

3,178 
1,122 

1,627 
168 

778 
96 

499 
63 

1,051 
114 

281 
24 

266 
19 

167 

8 

59 
5 

337 
11 

Grand  total 

9,873 

4,300 

1,795 

874 

562 

1,165 

305 

285 

175 

64 

348 

For  a  number  of  reasons  the  sickness  experience  of  this  combined 
group  of  employees  was  unusually  favorable  as  shown  by  the  fact  that 
only  13.6  per  cent  of  them  drew  benefits  on  account  of  sickness  and  "off 
duty  accidents."  The  great  importance  of  "off-duty  accidents,''  rheu- 
matism,  bronchitis  and  pleurisy,  grippe  and  colds,  and  diseases  of  the 
••  See  Part  n,  Special  Report  II. 


15 

alimentary  tract  will  be  noted.  The  importance  of  tuberculosis,  hernia 
and  heart  disease  is  understated,  however,  because  of  the  medical  ex- 
amination of  applicants  for  work  and  the  rejection  of  a  considerable 
number  of  those  suffering  from  these  diseases.  The  most  striking  thing 
shown  is  the  unusual  number  of  cases  lasting  more  than  180  days  where 
the  affliction  is  tuberculosis  or  heart  disease. 

The  Bureau  of  Labor  Statistics  has  tabulated  the  data  obtained 
from  the  Workmen's  Sick  and  Death  Benefit  Fund  by  duration  of  dis- 
ability, by  age  and  by  occupation.  The  average  for  cases  lasting  8  days  or 
more  varied  greatly  by  occupations,  the  minimum  being  2.8  days  for 
jewelers,  the  maximum  9.2  days  for  freight  handlers.  They  varied 
greatly,  also,  by  age,  from  4.1  days  at  age  25  to  10.7  at  age  65  and  13.5 
(for  17)  at  age  70.^^ 

(4)   The  Cost  of  Sickness. 

The  Commission  has  sought  to  secure  as  complete  data  as  possible  on 
the  cost  of  sickness  among  wage-earning  families.  A  summary  of  the 
results  is  presented  here. 

There  were  4,474  wage-earners  in  the  blocks  selected  for  study  in 
Chicago.  Of  these,  1,222  or  27.3  per  cent  had  been  seriously  sick  in 
the  course  of  the  year,  but  285  of  them  had  not  lost  as  much  as  a  week 
at  any  one  time.  Of  the  937,  who  did  lose  time,  usable  data  were  ob- 
tained for  901  who  lost  a  week  or  more.  The  earnings  of  these  901 
aggregated  $676,087;  their  wages  lost  because  of  sickness^  $107,338. 
The  wages  lost  were  13.7  per  cent  of  what  their  earnings  would  have 
been  but  for  sickness  and  an  average  of  a  little  more  than  $119  each.  If 
this  average  may  be  assumed  for  the  36  other  wage-earners  from  whom 
not  all  of  the  desired  data  were  secured,  and  the  total  loss  from  disability 
lasting  a  week  or  more  were  then  distributed  over  the  entire  number  of 
wage-earners  in  these  blocks,  it  would  give  an  average  wage  loss  of  $24.95 
each  for  the  year.  The  loss  (for  a  week  or  more)  would  be  about  3.33 
per  cent  of  their  total  earnings  as  reduced  by  disabling  sickness  for  these 
earnings  averaged  $750.37  per  wage-earner  for  the  year.  If  it  is 
assumed,  also,  though  the  assumption  may  involve  some  exaggeration, 
that  these  wage-earners  in  Chicago  were  typical  of  thj  approximately 
1,850,000  in  the  State,  the  yearns  losses  of  wages  because  of  sickness  dis- 
abling many  of  them  for  more  than  a  week  would  aggregate  $46,000,000. 

The  losses  indicated  become  serious  only  because  they  are  sustained 
by  a  minority  of  the  wage-earners  and  by  them  very  unevenly.     Taking  ^ 
901  who  lost  wages  for  a  week  or  more,  286  or  31.7  per  cent,  lost  less'  . 
than  5  per  cent  of  the  year's  earnings ;  221,  or  24.4  per  cent,  lost  5  but    . 
less  than  10  per  cent;  82,  or  9.1  per  cent,  lost  10  but  less  than  15  per    * 
cent;  99,  or  11.0  per  cent,  lost  15  but  less  than  20  per  cent;  83,  or  9.2 
per  cent,  lost  20  but  less  than  30  per  cent;  46,  or  5.1  per  cent,  lost  30' 
but  less  than  40  per  cent;  17,  or  1.9  per  cent,  lost  40  but  less  than  50 
per  cent;  52,  or  5.8  per  cent,  lost  50  but  less  than  75  per  cent;  and  15, 
or  1.7  per  cent,  lost  more  than  75  per  cent. 

To  the  loss  of  wages  must  be  added  the  direct  outlays  of  wage- 
earners  for  medical  care.     Of  the  1,222  disabled  by  sickness  1,100  had 

^  See  Part  II  of  this  report,  Special  Report  II. 


16 

sickness  costs  involving  lost  wages  or  direct  outlays  for  medicines  or 
medical  treatment  or  both.  Complete  data  obtained  for  1,019  of  these 
showed  direct  outlays  aggregating  $24,749--  as  against  an  aggregate 
wage  loss  of  $102,962.  These  figures  would  indicate  that  for  every 
dollar  of  wages  lost,  24  cents  must  be  added  for  medicines  and  medical 
treatment,  etc.  The  total  annual  bill  estimated  above  at  $46,000,000 
for  lost  wages  would  be  raised  to  more  than  $57,000,000  for  lost  wages 
and  medical  care  of  the  wage-earners  of  the  State. 

The  total  cost  of  sickness  borne  by  wage-earning  families  is,  of 
course,  considerably  larger  than  the  figure  just  used,  for  to  lost  wages 
and  direct  outlays  there  included  must  be  added  the  bills  incidental  to 
the  sickness  of  dependent  members  of  their  families.  The  studies  made 
of  more  than  forty  blocks  in  Chicago  covered  2,589  wage-earning  fami- 
lies,^^  who  reported  fully  on  disabling  sickness  and  income.  Seventeen 
hundred  forty-four,  or  67.1  per  cent  of  these  reported  disabling  sickness. 
Complete  data  were  secured  relating  to  the  incomes,  lost  wages,  and 
sickness  outlays  of  1,667  of  these  1,744  families.  Their  total  incomes 
amounted  to  $2,175,126,  their  total  sickness  cost  (lost  wages  and  outlays 
for  medical  treatment)  to  $163,340.  The  sickness  cost  was  8.3  per  cent 
of  their  wages  and  7.5  per  cent  of  their  incomes.  The  average  cost  was 
$97.98  per  family. 

While  it  was  impossible  to  secure  accurate  data  relating  to  the  total 
incomes  and,  in  some  cases,  the  total  earnings  of  the  77  families  report- 
ing disabling  sickness  but  not  included,  in  the  1,667  for  whom  the  com- 
parisons  have  just  been  made,  it  was  possible  to  secure  data  from  most  of 
them  for  wages  lost  and  outlays  for  medical  treatment.     Combining  the 
data  relating  to  lost  wages  for  75  of  these  (2  not  recorded)  with  those 
for  wages  lost  by  the  1,667,  a  total  of  $103,293  is  obtained  for  the  1,742 
families,  or  an  average  of  $59.30  each.     Assuming  /he  same  average  for 
the  two  cases  not  reported  and  spreading  this  wage  loss  over  the  2,598 
families  here  dealt  with,  the  average  loss  because  of  disabling  sickness 
recorded  would  be  $39.80  per  family.     All  told  direct  outlays  were  re- 
ported by  1,886  of  the  2,598  families.^*     Acceptable  and  complete  details 
could  be  obtained  for  only  1,733  of  these,  but  the  partial  details  obtained 
for  the  other  153  indicated  that  the  averages  would  be  about  the  same  for 
them  as  for  the  larger  group.     The  total  bills  paid  by  the  1,733  to 
doctors,  nurses,  hospitals,  dispensaries,  and  for  medicines  was  $74,511, 
or  an  average  of  $43  per  family.    Assuming  the  same  average  for  the 
153  other  families  reporting  some  of  their  outlays  and  distributing  the 
larger  total  over  the  2,598  families  studied  the  average  would  be  $31.21 
per  family.     This  is,  however,  an  understatement  of  tho  outlay.     Only 
72.6  of  the  families  studied  reported  any  medical  outlays;  more  intensive 
studies  of  household  budgets  have  shown  that  90  per  cent  or  more  have 
outlays  for  medicines  and  medical  treatment.     The  Bureau  of  Labor 
Statistics,  for  example,  has  recently  made  a  "cost  of  living*'  study  of 
215  wage-earning  families  connected  with  the  ship-building  industry  in 
Chicago.     The  unpublished  results  show  that  212  of  the  215  families 

»Thl8  figure  Includes  the  direct  outlays  of  a  considerable  number  who  did  not 
lose  wages  for  as  much  as  a  week  at  any  one  time. 
*»  The  head  of  the  family  was  a  wage-earner. 
»*Of  these  142  reported  no  "disabling  sickness"  of  the  kind  here  recorded 


17 

• 

studied  had  sickness  expenses  in  the  course  of  the  year,  the  average  for 
the  215  being  $39.17.^^  Though  these  families  were  earning  relatively 
high  wages  and  had  more  money  to  spend,  and  though  they  did  not  have 
the  same  opportunity  to  secure  free  treatment  that  was  open  to  most  of 
those  residing  in  the  blocks  studied  by  the  agents  of  this  Commission,  a 
comparison  of  the  results  convinces  us  that  the  small  imreported  sums 
spent  where  there  was  no  disabling  sickness,  would  add  $2  or  $3,  and 
possibly  more,  to  the  average  arrived  at  in  our  investigation.  Combin- 
ing lost  wages  and  direct  outlays  caused  by  sickness,  the  total  cost  per 
wage-earning  family  can  be  reckoned  as  more  nearly  $75  than  $70  per 
family  for  the  wage-earning  families  studied  in  these  Chicago  blocks. 
This  stands  out  against  an  average  family  income  of  $1,298,  of  which 
$1,215  was  received  in  wages. 

It  is  probable  that  the  cost  of  sickness  for  the  wage-earning  fam- 
ilies in  Illinois  in  lost  wages  and  direct  outlays  is  between  $80,000,000 
and  $86,000,000  per  year.^^  This  does  not  include  a  third  element  in 
cost,  viz.  loss  of  earnings  caused  by  impaired  efficiency. 

The  estimates  thus  far  made  do  not  include  funeral,  dental  and 
oculist  bills.  The  total  spent  on  112  funerals  covered  by  the  Com- 
mission's studies  of  wage-earning  blocks  in  Chicago  was  $14,833  or  an 
average  of  $132.40  each.  ^^  These  studies  show  that  dental  work  is 
greatly  neglected  by  most  families.  In  fact  only  981  of  the  2,598  fam- 
ilies, or  approximately  37.8  per  cent,  according  to  their  statements,  had 
had  any  dental  work  done  during  the  course  of  the  year.  Yet  the  total 
reported  as  spent  by  918  families  was  $27,671,  or  an  average  of  about 
$30.00.^^  The  Bureau  of  Labor  Statistics  in  its  investigations  to  which 
reference  has  just  been  made  found  that  the  outlays  for  dental  work, 
oculist  services  and  glasses  by  114  averaged  $12.24  for  the  entire  group 
of  215  families  studied. 

The  data  obtained  by  the  Commission's  agents  were  tabulated  for 
wage-earning  families  by  groups  on  the  basis  of  income  plus  wages  lost  by 
reason  of  sickness  and  need  of  income  in  view  of  the  family  composi- 
tion.^^ In  class  C  were  placed  those  families  who  could  not  meet  a  conser- 
vatively estimated  charity,  budget,  in  class  B  those  who  could  meet  such 
a  budget  but  who  had  a  margin  over  it  of  less  than  about  41  per  cent, 
in  class  A  those  with  a  lars^er  margin  than  this.  It  was  found  that  the 
percentages  of  such  families  with  disabling  sickness  were  76.0,  73.0 
and  63.4  for  classes  C,  B,  and  A  respectively.  Thus  the  less  well-off ^ 
families  on  the  basis  of  earnings  unreduced  by  sickness  were  found  to 
have  a  decided  excess  of  sickness.  It  was  found,  moreover,  that  the 
"sickness  costs"  of  families  in  class  C  were  14.9  per  cent  of  their  earn- 

25  Two  years  ago  the  Bureau  of  Labor  Statistics  investig-ated  the  expenditures 
of  1.059  wagre-earning-  families  in  Washing-ton,  D.  C.  Of  this  total  922  had  spent 
in  the  preceding-  year  an  averag-e  of  $37.75  for  medicines,  medical  treatment,  etc. 
The  average  for  692  (in  a  total  of  782)  white  families  was  $43.59;  for  230  (in  a 
total  of  277)  colored  families  $20.19.  (See  Monthly  Labor  Review,  November,  1917, 
pp.   9  et  seq.) 

2«  Figured  for  the  entire  State  at  the  average  cost  found  in  Chicago,  the  total 
would  be  approximately  $82,000,000.  As  has  been  stated,  however,  the  smaller  out- 
lays for  medicines  were  not  fully  reported. 

'^  There  were  more  deaths  but  the  exact  burial  costs  could  not  be  secured  in  all 
cases. 

^The  others  had  free  service  or  could  not  give  the  amount  spent. 

^For  an  explanation  of  this  grouping  see  Part  II,  Special  Report  I,  p.  i85. 

—2  H  I 


18 

ings  from  wages  as  against  8.5  per  cent  in  the  case  of  families  in  class 
B,  and  7.7  in  the  case  of  families  in  class  A.  Finally,  it  was  found  that 
a  relatively  larger  number  of  the  normally  less  well-off  families  had 
loss  of  wages  and  direct  outlays  for  medical  care  amounting  to  compara- 
tively large  sums.^°  Thus  the  distribution  of  the  cost  of  sickness  ap- 
pears to  be  decidedly  unfavorable  to  those  who  in  its  absence  are  least 
able  to  meet  a  pecuniary  burden. 

The  full  costs  of  sickness  have  not  yet  been  presented,  for  to  the 
lost  wages  and  direct  outlays  must  be  added  the  free  service  obtained 
by  many  presumably  because  they  were  unable  to  pay  for  it.  If  to  the 
wage-earning  families  dealt  with  above  242  otherwise  occupied  are 
added  (making  a  total  of  1,909),  we  find  that  273  had  free  physicians' 
service  as  against  1,338  that  paid  for  it;  122  free  nursing  service  as 
against  91  that  paid;  201  free  hospital  service  as  against  198  that 
paid  hospital  bills;  59  free  medicines  as  against  1,533  that  paid  for 
them;  226  free  dispensary  treatment  as  against  143  that  paid  dispensary 
fees.  Thus  the  doctors  contributed  their  services  in  almost  1  case  in  6, 
the  nurses  4  cases  in  7;  the  hospitals  in  more  than  1  case  in  2;  those 
who  provided  medicines  in  1  case  in  27;  the  dispensary  in  almost  3 
cases  in  5. 

Illness  has  been  found  to  give  rise  to  deficits  in  many  of  the  fam- 
ilies with  sickness.  Thus  290,  or  16.6  per  cent  of  the  1,744  wage- 
earning  families  with  sickness,  did  not  make  ends  meet  as  against  40, 
or  4.7  per  cent  of  854  without  sickness  who  were  involved  in  deficits. 
While  in  some  cases,  the  losses  due  to  sickness  were  small  and  would 
not  alone  account  for  the  deficiency,  in  a  large  percentage  of  the  cases 
the  losses  were  substantial.  Thus  taking  83  class  A  families  as  against 
16  whose  sickness  costs  were  less  than  $50  and  30  whose  costs  were  less 
than  $100,  the  costs  were  $100  or  over  in  53,  $150  or  over  in  45,  $200  or 
over  in  37,  $300  or  over  in  29,  $400  or  over  in  22,  and  $500  or  over  in 
16  cases.  Taking  73  class  B  families  with  slight  margins  over  necessary 
expenditures  at  all  times  as  against  26  whose  sickness  costs  were  less 
than  $50  and  39  whose  costs  were  less  than  $100,  the  costs  were  $100  or 
over  in  34,  $150  or  over  in  23,  $200  or  over  in  18,  $300  or  over  in  8, 
$400  or  over  in  4,  and  $500  or  more  in  2  cases.  Finally,  taking  66  class 
C  families  whose  earnings  unreduced  by  sickness  would  not  stand  the 
test  of  a  conservative  "charity  budget,^'  as  against  26  whose  sickness  cost 
was  less  than  $50  and  40  whose  cost  was  less  than  $100,  the  cost  was 
$100  or  over  in  26,  $150  or  over  in  20,  $200  or  over  in  19,  $300  or  over 
in  11,  $400  or  over  in  6,  and  $500  or  more  in  3  onsos.    It  must  be  borne 

*<>  The  details  may  be  presented  in  the  following-  form  : 

Percentage    of    families    with  sickness 
costs  in  class. 
.Hn«««             Sickness  costs  in  excess  of —                          ABC 

^JSS-^2    31.3                    26.6  34.1 

2JXJ0    16.6                    12.3  17.9 

JOOJO    11.2                      7.0  8.4 

400.00    60                      41  f^n 

500.00 ::::.:.::::  3.6  I:?  3:4 

The  average  costs  for  families,  thus  grouped,  was  as  follows : 

Average  loss  of     Average  of  direct 

Class.  wages.  outlays.  Average  cost. 

^    $57.05  $45.68  $102.73 

^    47.03  35.84  82.87 

^    62.15  45.18  107.33 


19 

in  mind  that  the  sickness  costs  used  for  the  above  comparisons  include 
not  only  the  actual  expenditures  but  also  the  estimated  wage  loss.  They 
are  designed  to  show  the  change  from  the  normal  situation  caused  by 
loss  of  earnings  and  medical  outlays. 

The  ways  in  which  these  deficits  were  met  are  significant.  Data 
for  247  of  the  290  show  that  35  obtained  $6,584  in  charity  ;2^  64,  $8,868 
in  loans;  37  used  $7,305  from  previous  savings;  104  left  bills  unpaid 
amounting  to  $8,350;  32  used  $4,938  received  from  insurance;  and 
14  met  deficits  to  the  extent  of  $2,168  in  other  ways.  This  indicates 
that  by  no  means  all  the  cost  of  sickness  is  met  by  the  families  visited 
by  such  misfortune. 

(5)   Sickness  and  Changes  in  the  Standard  of  Living;  Sickness  and 
Poverty. 

Sickness  is  a  disturbing  factor  in  the  family  life,  frequently  causing 
undesirable  changes  in  standards  of  living  and  at  times  giving  rise  to 
the  necessity  of  seeking  charity  in  other  forms  than  medical  care. 

Changes  in  standards  of  living  are  difficult  to  ascertain  and  measure 
in  investigations  of  the  type  made  by  the  Commission's  agents.  In  the 
great  majority  of  cases  they  take  the  form  of  smaller  expenditures  for 
food,  clothing,  dental  care,  and  the  like,  but  these,  while  important, 
cannot  be  ascertained  and  set  down  in  definite  form.  Some  definite  data 
were,  however,  obtained,  and  may  be  briefly  presented. 

A  tabulation  has  been  made  of  the  wage-earning  families  studied 
in  working  class  districts  in  Chicago  by  what,  foi'  want  of  a  better  term, 
has  been  called  "economic  status."  In  class  C  are  placed  those  who  in 
any  event  have  only  a  conservatively  estimated  poverty  budget;  in  class 
B  those  who  without  reckoning  out  loss  of  wages  and  medical  bills  due  to 
sickness,  have  a  margin  of  not  more  than  41  per  cent  over  the  poverty 
budget;  in  class  A  those  who  without  reckoning,  out  loss  of  wages  and 
medical  bills,  have  a  margin  of  not  more  than  25  per  cent  over  the  maxi- 
mum for  class  B;  in  class  W  those  who  have  more  adequate  incomes, 
loss  of  wages  and  medical  bills  left  out  of  the  account.  This  is  a  group- 
ing on  the  "normal"  basis  undisturbed  by  sickness  losses  and  outlays. 

^Taking  the  families  thus  grouped,  it  was  found  that  a  total  of  343  out 
of  a  grand  total  of  2,598  wage-earninsc  families  were  shifted  to  a  lower 
class  when  loss  of  wage  and  medical  bills  caused  by  sickness  were  taken 
into  consideration.  The  number  of  "W"  families  changed  from  1.022 
to  893 ;  the  number  of  "A"  families  from  665  to  644 ;  the^number  of  "B" 
families  from  631  to  686;  the  number  of  "C"  families  from  280  to  375. 

^In  the  343  shifts  to  a  lower  class,  the  disabling  illness  of  normal  bread- 
winner (the  father)  was  assigned  as  the  sole  cause  in  165  cases  and  as  a 
part  cause  (in  conjunction  with  the  illness  of  other  members  of  the 
family),  in  43  additional  cases.  These  data  give  some  idea  of  the  re- 
adjustments which  had  to  be  made  in  the  absence  of  savino^s  and  with 
little  insurance.  So  do  the  sums  lost  bv  reason  of  sickness  as  indicated 
in  the  preceding  section.     Yet  the  shift  to  a  lower  class  just  indicated 

^^  In  this  investig-ation  50  families  were  found  to  have  been  in  receipt  of  charity 
in  the  course  of  the  year.  In  six  of  these  families  there  had  been  no  sickness  ;  in 
44  there  had  been,  but  9  of  these  were  among  the  43  families  for  which  complete 
data  were  not  secured. 


20 

does  not  present  the  situation  fully,  for  in  a  considerable  number  of 
cases  members  of  families,  until  then  unoccupied,  took  employment  to 
make  good,  in  part  at  least,  the  losses  sustained. 

In  their  "block  investigations"  the  agents  of  the  Commission  found 
74  families  in  a  total  of  1,744  wage-earning  families  with  sickness  re- 
corded, in  which  the  wife,  or  children  under  16,  or  older  children  had 
gone  to  work  because  of  the  strain  on  family  income  produced  by  sick- 
ness. The  ratio  of  1  in  less  than  24  is  no  doubt  an  understatement 
for  the  positive  evidence  obtained  was  not  complete.  But  taking  the 
evidence  obtained,  39  wives  had  gone  to  work,  as  did  young  persons  16 
and  over  in  16  families,  and  children  under  16  in  19  families.  Fifteen 
other  families  had  moved  to  cheaper  quarters,  while  20  had  permitted 
insurance  to  lapse  because  of  the  strain  produced  by  sickness. 

Investigations  made  elsewhere  than  in  Illinois  show  that  disabling 
sickness  may  be  charged  with  about  a  quarter  of  dependency  not  cared 
for  in  almshouses  and  similar  institutions.^^  The  reports  made  to  the 
Commission  by  charity  organization  societies  of  eight  Illinois  cities 
assign  sickness  as  the  chief  cause  of  approximately  one-third  of  all  de- 
dependency  in  1917-18.  Our  investigation  of  the  data  provided  by 
Chicago  charitable  agencies  for  an  eight  year  period  indicates  that 
physical  and  mental  disability  is  designated  in  one-third  to  one-half  of 
all  analyzed  causes  and  problems  of  dependency.  The  lower  dependency 
ratio  ascribed  to  sickness  by  other  investigators  was  found  to  be  due  to 
the  fact  that  their  studies  were  made  in  years  abnormal  for  poverty  and 
dependency  by  reason  of  an  unusual  degree  of  unemplo^rment.  Of  the 
2,708  wage-earning  families  covered  by  the  "block  studies"  only  50,  or 
1.8  per  cent,  reported  charitable  assistance  other  than  free  medical  and 
nursing  care  during  the  year.  Checking  this  finding  against  other 
sources  of  information  the  estimate  mav  be  ventured  that  somewhat 
under  2  per  cent  of  Chicago  wage-earning  families,  the  lowest  proportion 
in  a  decade,  were  recipients  of  material  relief  from  the  organized  chari- 
ties of  the  City  during  the  year  1917-18. 

As  important  as  determining  the  percentage  of  dependency  due  to 
disabling  sickness  was  the  problem  of  ascertaining  the  tj^pe  of  physical 
and  mental  disability  responsible  for  dependency.  For  an  eight  year 
period  the  United  Charities  reports  that  one-half  of  all  physical  dis- 
ability except  that  arising  from  accident  is  due  to  acute  illnesses;  the 
other  half  is  due  to  chronic  diseases  about  evenly  divided  between  tuber- 
culosis and  all  other  chronic  disorders.  The  Cook  County  Agent  assigns 
three-fifths  of  all  physical  disabilities  aside  from  injury  by  accident  to 
acute  ailments,  one-fifth  to  tuberculosis  and  one-fifth  to  other  chronic 
diseases.  The  special  investigation  made  (in  1918)  by  the  Commission 
on  the  distribution  of  disabling  sickness  other  than  injury  from  acci- 
dent in  the  628  charity  families  included  in  the  family  study  found  a 
much  smaller  proportion  of  disabling  sickness  of  the  type  of  acuta^ill- 
nesses.^^    The  time  of  year  (May  and  Jime)  when  the  cases  were  selected 

*2  The  whole  matter  of  the  relation  between  sickness  and  poverty  and  dependency 
has  been  studied  intensively  for  the  Commission  by  Professor  E.  W.  Burgess.  For 
a  full  analysis  and  statement  of  his  results,  see  Part  II  of  this  report,  Special  Report 
I,  Sec.  V. 

''  See  Part  II,  Special  Report  I,  p.  257. 


21 


and  the  conditions  of  this  special  investigation  were,  however,  largely 
responsible  for  the  lower  figure.  Even  if  responsible  for  only  two-fifths, 
rather  than  one-half  or  more  of  disability  other  than  that  caused  by  acci- 
dent, chronic  diseases  stand  out  characteristically  as  thj  long  time  dis- 
abling type  of  sickness.  One  chronic  disability  alone,  tuberculosis,  is 
charged  with  one-fifth  to  one-fourth  of  all  physical  disability  other  than 
that  arising  from  accident. 

The  relation  of  sickness  to  the  process  of  economic  degradation  was 
ascertained  in  two  wavs.  First,  the  normal  economic  status  of  the 
family  for  the  year  was  determined  by  using  as  a  basis  the  family  in- 
come augmented  by  wages  lost  from  sickness.  Of  the  608  charity  fam- 
ilies reporting  income  in  full  the  normal  economic  status  of  only  68  was 
in  class  A  with  moderate  incomes;  139  in  class  B  with  meagre  incomes, 
and  401  in  class  C  with  deficient  incomes.  The  following  table  presents 
an  interesting  comparison  between  the  normal  economic  status  of  the 
2,708  wage-earning  families  in  our  block  studies  and  that  of  the  628  de- 
pendent families  which  has  a  significant  bearing  upon  the  question  of 
the  relation  of  sickness  to  economic  degradation.  ,^ 


Number  of  families  in — 

Per  cent  families  in — 

Normal  economic  status. 

Block 

study. 

Charity 
study. 

Block 
study. 

Charity 
study. 

Class  A  with  moderate  income 

1,687 
631 

280 
110 

68 

139 

L401 

>k20 

62.3 

23.3 

10.3 

4.1 

10.8 

Class  B  with  meagre  income        

22.1 

Class  C  with  deficient  income ; 

63.9 

Class  D  income  not  reported 

3.2 

Total 

2,708 

628 

100.0 

100.0 

Assuming  that  the  wage-earning  families  in  the  blocks  studied  are 
fairly  representative  of  the  Avage-earning  group  in  Chicago  and  that  the 
families  in  the  charity  study  are  typical  of  dependency  caused  by  sick- 
ness, the  general  principle  of  economic  degradation  may  be  formu- 
lated:— the  effect  of  sickness  as  a  factor  making  for  dependency  varies 
inversely  with  the  level  of  the  normal  economic  status  of  the  family. 

The  following  statistical  detail  is  significant  in  connection  with  the 
relation  between  sickness  and  dependency.  The  total  number  of  persons 
in  these  charity  families  was  3,475;  of  these  1,546  were  sick  in  the  course 
of  the  year.  Wage-earners  were  sick  in  84.5  per  cent  of  the  families  and 
the  sickness  of  others  added  to  the  difficulty  in  more  than  two-thirds  of 
these  cases.  Of  the  wage-earners  losing  a  week  or  more  of  employment 
450  reported  completely  in  respect  to  earnings  and  lost  wages.  Their 
earnings  aggregated  $183,841;  their  losses  of  wages  due  to  sickness 
$104,493,  or  35.9  per  cent  of  what  their  earnings  would  have  been  but 
for  illness,  and  an  average  of  $258  each.  Of  450  losing  working  time, 
279  lost  more  than  one-fifth  of  the  full  time  reduced  possibly  by  unem- 
ployment for  other  reasons  than  sickness,  165  more  than  two-fifths,  136 
more  than  half,  and  63  three-fourths  or  over. 

Taking  figures  for  charity  families  as  a  whole,  of  408  reporting  loss 
of  earnings  and  direct  outlays  on  account  of  sickness,  the   combined 


22 

• 
figure  for  these. was  $100  or  more  in  258  cases;  $200  or  more  in  183; 
$300  or  more  in  134;  $400  or  more  in  91 ;  and  $500  or  more  in  57.  The 
average  in  these  408  cases  was  something  over  $244  per  family.  Of 
this  85  per  cent  represented  loss  of  wages,  15  per  cent  doctors'  bills, 
hospital  bills,  etc.,  which  totaled  $14,899.  There  was,  however,  more 
free  medical  treatment  in  these  cases  than  treatment  paid  for.  As 
against  168  who  paid  doctors'  bills,  247  had  free  service;  as  against  46 
who  paid  hospital  bills,  276  had  free  beds;  as  against  8  who  paid  some- 
thing for  nursing  care,  166  had  free  service;  as  against  19  who  paid 
dispensary  fees,  239  paid  nothing;  as  against  210  who  paid  for  their 
medicines;  80  paid  nothing. 

The  second  method  of  measuring  the  extent  to  which  economic 
degradation  was  caused  by  sickness  was  to  determine  the  economic  stand- 
ing of  the  family  prior  to  the  present  cause  ot  distress.  In  291  cases 
data  were  present  in  the  records  examined  showing  whether  the  family 
had  been  independent  or  dependent  before  the  present  occasion  of 
dependency.  One  hundred  forty-nine  of  these  families  were  found  to 
have  been  normally  independent,  and  142  famines  dependent  or  in 
serious  economic  difficulty  before  the  distress  which  resulted  in  the 
present  dependent  status.  It  should  be  taken  into  account  however, 
that  of  these  142  families,  (with  28  reports  deficient  and  not  tabulatable) 
40  were  known  to  have  been  dependent  before  on  account  of  sickness. 
Thus  in  more  than  1  case  in  3  the  earlier  dependency  was  connected 
with  sickness. 

Our  investigation  shows  clearly  how  extensively  the  size  of  the 
family  enters  into  the  problem  of  poverty  and  dependency,  complicating 
the  relative  weight  of  other  factors,  such  as  disabling  sickness.  The 
percentage  of  fapiilies  with  only  one  wage-earner  and  four  or  more 
children  14  years  of  age  or  under  was  in  the  blocks  studied  9.7  per  cent, 
in  the  628  charity  families  36.5  per  cent.  In  the  charity  families  it  was 
found  that  large  families  of  this  type  constitute  34.7  per  cent  of  the 
families  dependent  because  of  accidental  injury  sustained  by  the  normal 
breadwinner;  42.9  per  cent  of  the  families  receiving  charity  because  of 
chronic  disability  of  the  normal  breadwinner;  and  45  per  cent  of  the 
families  receiving  relief  because  of  acute  illness  of  the  normal  bread- 
winner. 

What  inferences  are  to  be  drawn  from  these  different  percentages? 
The  basic  fact  stands  out  that  the  great  majority  of  families  with  only 
one  breadwinner  and  four  or  more  children  not  over  14  years  of  age  are 
already  in  poverty,  just  at  the  edge  of  dependency.  An  acute  illness 
pushes  the  family  into  dependency  because  of  its  necessary  '"hand  to 
mouth"  existence.  Chronic  illness  depresses  the  family  for  long  periods 
into  the  dcponrloncy  status. 

(6)  Some  Illinois  Vital  Statistics. 

It  was  only  recently  that  the  reports  of  deaths  became  complete  ' 
enough  in  Illmois  for  the  State  to  be  added  by  the  Bureau  of  the  Census 
to  what  is  known  as  "the  registration  area."«*    Hence  the  only  reliable 

♦»,.    **7^^  rogrlstration  area  now  includes  states  and  parts  of  other  states  with  c,nm^ 
thing  less  than  three-fourthe  of  the  population  of  <he  United  Statis 


23 

vital  statistics  available  for  the  State  as  a  whole  are  those  recently  pre- 
sented for  the  year  1917-1918  by  the  Division  of  Vital  Statistics  of 
the  Department  of  Public  Health.  The  Commission  had  hoped  to  be 
able  to  present  these  in  some  detail  so  as  to  throw  light  on  the  many 
phases  of  the  problems  here  dealt  with.  In  this,  however,  it  has  been 
disappointed  for  the  Division  of  Vital  Statistics  reports  that  because 
of  unexpected  delays  the  detailed  tabulations^"  being  made  will  not  be 
completed  until  March.  Under  the  circumstances  the  Commission  must 
use  less  desirable  data  and  refer  those  interested  to  the  tabulations 
to  be  made  available  later  by  the  Department  of  Public  Health. 

The  number  of  deaths  occurring  in  Illinois  between  July  1,  1917 
and  June  30,  1918,  as  reported  to  the  Department  of  Public  Health, 
was  89,428.  With  a  population  estimated  for  the  mid-year  (January 
1,  1918)  at  6,276,364,  this  gives  a  death  rate  for  Illinois  of  14.2  per 
1,000.  This  corresponds  closely  to  the  death  rate  (14.0)  as  reported 
for  1916  for  the  entire  registration  area.  It  is  somewhat  less  than  the 
death  rates  reported  in  Ohio  (14.4)  and  Pennsylvania  (14.6),  but  is 
slightly  in  excess  of  the  rate  reported  for  Indiana  (13.6),  and  con- 
siderably in  excess  of  the  rates  reported  for  Wisconsin  (11.8)  and 
Minnesota  (10.7).  Too  great  reliance  must  not  be  placed  upon  these 
figures  for  the  several  states,  however,  for,  as  is  well  known,  the  census 
estimates  of  population  may  err  considerably  and  are  likely  to  require 
extensive  readjustment  when  the  next  census  is  taken — in  1920.^^  Yet 
it  may  be  said  that  the  close  correspondence  between  the  death  rate 
for  Illinois  and  those  for  such  states  as  are  similarly  circumstanced, 
e.  g.  Ohio  and  Pennsylvania,  and  that  for  the  entire  registration  area, 
would  suggest  that  there  is  nothing  peculiar  in  the  problem  of  disease 
and  fatal  sickness  in  this  state.  The  problem  here  dealt  with  is  not 
particularly  different  from  the  problem  in  other  states  with  much  the 
same  employment  and  population  groups. 

Of  course  the  death  rates  reported  for  the  several  counties  and 
cities  in  Illinois  vary  greatly,  but  perhaps  as  much  because  of  inaccurate 
estimates  of  population,  differences  in  age  distribution  (of  great  im- 
portance in  connection  with  the  death  rate)  and  different  degrees  of 
incompleteness  in  reporting  deaths,  as  because  of  differences  in  sanitary 
and  other  conditions  affecting  the  amount  of  sickness.  Leaving  out 
of  comparison  the  counties  where  the  population  is  reported  at  the 
figure  for  1910,^^  the  reported  death  rates  in  Illinois  in  1917-1918 
varied  between  5.5  for  Lawrence  County  and  16.6  and  17.4  for  Eock 
Island  and  Cook  Counties.  So  many  differences  must  be  taken  into 
consideration  that  when  added  to  the  fact  that  population  estimates 
may  err  greatly,  it  is  perhaps  undesirable  to  make  comparisons  between 

35  These  would  show  for  each  county  and  city  of  the  State,  the  number  of  deaths 
due  to  childbirth,  the  number  of  deaths  of  children  under  1  year  of  age  and  deaths 
by  cause,  age,  sex,  occupation,  and  race. 

^  It  is  to  be  regretted  that  accurate  population  figures  are  lacking.  Their 
absence  introduces  much  room  for  error  in  comparisons  not  only  between  this  and 
other  states,  but  also  between  different  cities  and  counties  in  Illinois. 

2'  Certain  cities  and  counties  were  found  to  have  smaller  populations  in  1910 
than  in  1900.  In  these  cases  the  Census  uses  the  1910  figures  as  the  estimates  of 
present  population.  In  the  other  cases,  the  estimates  are  arrived  at  by  adding  to 
the  1910  Census  count  figures  determined  by  the  rate  of  increase  between  1900  and 
1910. 


24 


I 


cities.3«  It  may  be  noted,  however,  that  Chicago,  largely  because  of  a 
better  public  health  service  than  is  found  in  most  parts  of  the  State,  in 
1917-18  had  a  death  rate  of  13.6. 

As  already  stated,  no  acceptable  vital  statistics  for  Illinois  as  a 
whole  are  available  for  any  year  except  1917-1918.  There  can  be  no 
doubt,  however,  that  there  has  been  a  declining  death  rate  closely  cor- 
responding to  that  shown  for  the  registration  area  as  a  whole.  The 
death  rate  for  the  United  States  has  decreased  from  19.8  per  thousand 
in  1880  to  14.0  per  thousand  in  1916.  Eevised  figures  furnished  by  the 
Health  Department  show  that  the  death  rate  in  Chicago  decreased  from 
20.27  in  1887  to  14.92  in  1917,  a  decrease  of  26.4  per  cent  in  a  period 
of  31  years.  Figures  available  for  shorter  periods  for  seven  other 
registration  cities  in  Illinois  show  in  general  a  similar  decrease.^^ 
Whether  or  not  there  has  been  a  corresponding  decrease  in  rural  com- 
munities in  Illinois  is  not  known,  but  taking  the  registration  area  as  a 
whole  the  decrease  shown  for  the  cities  has  been  greater  than  that  for  the 
rural  sections. 

The  vital  statistics  of  the  city  of  Chicago  when  presented  by  causes 
of  death  are  of  importance  in  connection  with  the  Commission's  prob- 
lems. They  are  presented  by  five-year  periods  in  the  following  table. 
These  five-year  periods  are  used  because  of  the  relatively  large  fluctua- 
tions from  vear  to  year. 

It  will  be  noted  that  the  causes  specified  account  for  72.2  per  cent 
of  the  deaths  for  the  period  1887-1891,  and  for  84.9  per  cent  of  the 
entire  number  during  the  period  1912-1916.  The  important  things 
shown  by  the  table  are  as  follows: 

(1)  A  decrease  in  the  average  death  rate  for  1887-1891  from 
204.1  per  10,000  population  to  145.7  for  1912-1916— a  reduction  of 
28.6  per  cent; 

(2)  Most  of  this  decrease  appears  to  have  occurred  during  the 
first  ten  of  the  thirty  years  covered  by  the  table; 

(3)  A  decrease  in  the  death  rate  from  typhoid  from  8.22  to  0.71 
— due  largely  to  improved  supplies  of  water  and  milk ; 

(4)  A  decrease  in  the  death  rate  from  pulmonary  tuberculosis 
from  17.9  to  14.01 — a  decrease  of  approximately  a  fifth; 

(5)  A  slight  increase  in  the  death  rate  from  pneumonia; 

(6)  An  increase  in  the  death  rate  from  cancer  from  4.29  to  8.54 
or  99.1  per  cent,  so  that  it  accounted  for  5.9  per  cent  of  the  entire 
number  of  deaths  in  1912-1916  as  against  2.1  per  cent  in  1887-1891. 

**  For  death  rates  reported  for  the  larger  cities  of  the  State,  see  Anmial  Reports 
to  the  Governor   (1917-1918),  pp.   487-490. 

'•The  seven  registration  cities  in  Illinois,  other  than  Chicago,  have  been: 
Aurora,  Belleville,  Decatur,  Evanston,  Jacksonville,  Quincy,  and  Springfield.  Their 
death  rates  per  1,000  for  the  first  year  reported  by  the  Census  Statistics  of  Mor- 
tality and  for  1916  was  as  follows: 

Death  rate  first 
City.  year  reported.  Death  rate,  1916. 

Aurora    15.90(1900)      13.77 

Belleville  - 15.27  (1900)      14.75 

Decatur    16.92(1900)      12.84 

Evanston    10.07(1908)      12.85 

Jacksonville   17.77  (1900)      35.20  (29.37  in  1915) 

Quincy 15.67  (1900)      16.58  (15.34   in   1915) 

Springfield..... 17.71(1900)      15.97 

Jacksonville  s  experience  is  not  at  all  comparable  during  the  period  or  with  that 
of  the  other  cities  because  it  is  greatly  affected  by  the  presence  of  a  State  institution 


25 


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(7)  An  increase  in  the  death  rate  from  heart  disease  from  7.11 
to  16.3,  or  129.3  per  cent,  so  that  it  accounted  for  11.2  per  cent  of  the 
deaths  in  the  last  as  against  3.5  per  cent  in  the  first  five-year  period; 

(8)  An  increase  in  the  death  rate  from  Bright's  disease  from  4.42 
to  9.15,  or  107  per  cent,  so  that  it  accounted  for  6.3  per  cent  of  the 
deaths  in  the  last  as  against  2.2  per  cent  in  the  first  period; 

(9)  An  increase  in  the  combined  death  rate  for  cancer,  heart  dis- 
ease and  Bright^s  disease  from  15.82  to  33.99  or  114.7  per  cent,  so 
that  the  three  accounted  for  23.3  per  cent  of  the  deaths  in  the  last  as 
against  7.75  in  the  first  period; 

(10)  A  decrease  in  the  combined  death  rates  from  croup,  diph- 
theria, scralet  fever,  measles  and  whooping  cough  from  21.32  to  6.4  or 
70  per  cent,  so  that  they  accounted  for  4.4  per  cent  of  all  deaths  in  the 
last  as  against  10.45  per  cent  in  the  first  period. 

A  factor  explaining  the  striking  decrease  in  the  number  of  deaths 
due  to  children's  diseases  and  the  striking  increase  in  the  death  rates 
due  to  cancer,  heart  disease  and  Bright's  disease  is  found  in  the  change 
in  the  age  distribution  of  the  population.  Between  1890  and  1910  the 
percentage  of  persons  under  15  years  of  age  decreased  from  32.3  to 
27.5;  the  percentage  of  persons  45  years  of  age  or  over  increased  from 
13.6  to  17.3.  It  is  evident,  however,  that  these  changes  are  after  all  a 
minor  factor  in  explaining  the  decrease  in  the  one  case  and  the  in- 
crease in  the  other.  Just  as  the  purification  of  the  water  supply  and 
the  improvement  in  the  milk  supply  have  effected  a  striking  decrease 
in  the  ravages  of  typhoid  and  improved  living  conditions  and  perhaps 
the  development  of  a  degree  of  unanimity  have  decreased  the  death 
rate  from  tuberculosis,  so  has  the  control  of  communicable  disease  re- 
duced the  death  rates  from  the  several  children's  diseases.  Then,  too, 
antitoxin  has  greatly  reduced  the  number  of  fatalities  from  diphtheria. 

In  these  matters  Chicago's  experience  eorresponds  to  that  of  the 
country  at  large  as  shown  by  the  Census  figures  on  mortality.  No  doubt 
the  changes  in  Illinois  as  a  whole  have  differed  from  those  in  Chicago 
only  in  degree.  The  fact  is  that  the  great  reduction  in  the  death  rate 
has  been  due  chiefly  to  the  striking  reduction  in  deaths  of  children; 
the  reduction  in  the  death  rate  among  persons  in  middle  life  has  not 
been  nearly  so  great,  while  that  among  persons  past  fifty  years  of  age 
has  increased.*^  As  has  been  said,  "There  has,  unquestionably,  not  been 
the  progi'ess  in  the  control  of  the  diseases  of  adult  life  which  has  been 
achieved  in  the  prevention  of  the  acute  infectious  diseases  of  infancy 
and  early  youth.    If  there  has  not  been  the  alarming  increase  to  which 

*°  Dr.  F.  H.  Hoffman  in  an  article  in  the  Journal  of  the  Atnerican  Institute  of 
Homeopathy,  Vol.  X.  pp.  1084-1096,  presents  the  following  table  based  upon  the 
Census  Mortality  Statistics  for  1910  and  1915  : 

Mortality  in  Registration  States. 

Percentage 

Rate  per  1,000  population.  increase 

Ages.                                                1900.  1915.  or  decrease. 

10-19    3.87  2.58  —33.3 

20-29    -...                    7.30  4.87  —33.3 

30-39    9.10  7.04  —22.6 

40-49    11.96  10.94  —    8.5 

50-59    19.78  19.95  -\-    0.9 

60-69    38.20  40.43  -{-     5.8 

70-79    83.01  86.49  +    4.2 

80  and  over 193.39  190.64  —    1.4 

All  ages 17.12  14.27  —16.6 


27 

the  attention  is  directed  by  those  who  apparently  are  not  fully  aware 
of  the  limited  value  or  even  the  misleading  nature  of  the  statistics 
used  there  has  certainly  not  been  the  anticipated  decrease  in  the  death 
rate  which  for  humane,  social  and  economic  reasons  would  be  of  the 
first  importance  to  the  nation/^*^ 

Whether  or  not  there  has  been  an  increasing  or  a  decreasing  amount 
of  sickness  accompanying  the  decreasing  death  rate  has  not  been  es- 
tablished by  statistics.  There  is  of  course  a  close  relation  between  the 
amount  of  sickness  and  the  death  rate.  The  death  rate  depends,  however, 
upon  the  efficiency  of  medical  and  surgical  treatment  as  well  as  upon 
the  number  who  have  serious  illness.  With  the  development  of  antitoxin 
the  number  of  fatalities  per  100  cases  of  diphtheria  has  been  strikingly 
reduced;  with  the  exercise  of  greater  care  and  improvement  in  the 
treatment  of  tuberculosis  no  doubt  fewer  cases  have  been  fatal;  with 
more  accurate  diagnosis  and  better  surgery  the  number  of  cases  of 
recovery  from  appendicitis  has  increased ;  and  the  same  is  true  of  a  num- 
ber of  other  diseases.  The  decided  decline  in  the  death  rate  may  have 
been  accompanied  by  less  morbidity.  It  is  possible,  however,  that  the 
amount  of  sickness  has  increased. 

(7)   Conditions  and  Behavior  Causing  Disease  and  Death. 

The  amount  of  sickness  and  the  number  of  deaths  are  affected  by 
many  conditions  and  by  personal  conduct  or  behavior.  These  conditions 
may  be  grouped  under  working  conditions,  living  conditions  and  com- 
munity conditions.  Save  for  an  investigation  of  "The  Health  of  Illinois 
Coal  Miners''  by  Dr.  E.  E.  Hayhurst,*^  the  Commission  has  made  no 
special  investigations  of  these  matters  in  Illinois.  In  stating  the 
problem  in  its  relations  to  conditions  and  behavior,  use  will  be  made  of 
data  drawn  for  the  greater  part  from  other  sources. 

W^ork  with  harmful  substances,  work  under  unsanitary  or  other 
harmful  conditions,  and  perhaps  fatigue  give  rise  to  an  excessive  amount 
of  sickness  and  increase  the  number  of  premature  deaths.  In  some 
instances  specific  cases  may  be  definitely  and  directly  traced  to  the 
materials  worked  with  or  to  certain  conditions  in  the  place  of  work. 
Such  is  occupational  disease — lead  poisoning,  arsenical  poisoning, 
anthrax,  caisson  disease  and  the  like.  In  Great  Britain  twenty-eight  of 
these  occupational  diseases  have  been  brought  under  the  Workmen's  Com- 
pensation Act.  Occupational  disease  presents  an  important  problem; 
yet  in  California  and  Massachusetts  the  number  of  occupational  disease 
cases  compensated  under  the  workmen's  compensation  laws  has  been 
very  small  as  compared  to  the  number  of  accidents  compensated,  and 
still  smaller  as  compared  to  the  number  of  cases  of  disabling  sickness."*^ 
The  reason  why  so  few  cases  are  compensated  in  these  states  is  found 
in  the  difficulty  involved  in  establishing  a  direct  and  immediate  relation 
in  the  individual  case  between  the  specific  disease  and  the  nature  of  the 
work  or  the  conditions  under  which  it  is  done.     Conditions  connected 


"  Quoted  from  Frederic  H.  Hoffman,  "Is  the  Increasing  Death  Rate  from  the 
'Degenerative'  Diseases  Imaginary?,"  in  Journal  of  the  American  Institute  of  Home- 
opathy, Vol.  X,  p.  1095. 

"  See  Part  II,  Special  Report  V. 

"  See  Part  II,  Special  Report  IV,  and  Special  Report  XVI.  Special  Report  IV 
is  a  stimmary  statement  of  Occupational  Disease  in  Illinois,  by  Dr.  Alice  Hamilton. 


28 

with  the  gaining  of  a  livelihood  do  not  record  their  results  in  recognized 
occupational  disease  alone.     There  is  fairly  general  agreement  that  this 

is  true. 

Unsanitary  conditions  (dirt,  dust,  dampness),  bad  lighting,  bad 
ventilation,  excessive  heat  and  cold  in  the  place  of  work  record  their 
effects  upon  wage-earners.**  To  what  extent  these  are  found  in  Illinois 
the  Commission  has  not  ascertained  by  investigation.  These  conditions 
are  covered  by  legislation  and  it  is  a  matter  of  common  knowledge  that 
they  have  shown  considerable  improvement  during  the  last  ten  years. 
An  increasing  number  of  establishments  maintain  their  own  inspection 
departments  to  secure  sanitary  conditions.  Yet  it  can  neither  be  said 
that  there  are  no  laggards  in  improving  the  hygiene  of  work  places,  nor 
be  claimed  that  the  best  that  sanitary  science  has  to  offer  has  found 
general  application  in  practice.  A  survey  made  for  the  State  Board  of 
Health  in  Ohio  in  1914  showed  exposure  to  the  hazards  mentioned 
above,  and  classified  as  "bad"  from  the  standpoint  of  sanitation  and 
hygiene,  in  a  considerable  number  of  the  industrial  establishments  in- 
spected.*^ Investigations  in  New  York  and  Louisiana  have  shown 
similar  results.  Sanitary  surveys  made  for  the  Commission  on  In- 
dustrial Relations  by  the  United  States  Public  Health  Service  in  ten 
typical  industries  in  seven  different  states,  among  them  Illinois,  are  said 
to  have  shown  "that  conditions  were  about  the  same  as  those  reported 
for  New  York,  Louisiana,  and  Ohio.''*® 

Fatigue,  due  to  the  accumulation  of  waste  products  within  the 
system  called  fatigue  poisons  and  fatigue  toxins,  is  said  by  some  to  be 
one  of  the  most  common  causes  of  occupational  disability.  It  is  claimed 
that  it  may  cause  "anemia,  enlargement  of  the  heart,  increased  blood 
pressure,  circulatory  diseases,  kidney  disease  and  neurasthenia  or  nervous 
exhaustion."*^  Fatigue  may  be  caused  by  many  things  in  industry — 
standing  at  work,  strained  positions,  noise,  monotony  of  work  due  to 
specialization,  unusual  concentration  of  attention,  speed  induced  by  piece 
work  or  otherwise,  long  hours  per  day  or  the  seven  day  week^  alternate 
night  and  day  work,  etc.  Of  these  speed  on  piece  work  and  long  hours 
are  perhaps  of  most  importance.  The  physical  examination  of  garment 
workers  in  New  York,  conducted  by  the  United  States  Public  HealtH 
Service,  showed  more  frequent  overstrain  on  the  part  of  piece  workers 
than  on  the  part  of  those  otherwise  paid.*^ 

The  Industrial  Survey  Commission  of  this  State  has  recently  (1918) 
made  an  investigation  of  the  relation  between  health  and  the  hours  of 
employment  of  women.  A  number  of  industrial  physicians  in  their 
communications  to  this  Survey  Commission,  stated  that  long  hours  and 
standing  while  at  work  give  rise  to  certain  complaints,  which  in  some 
cases  were  set  out  in  detail.*®    A  statistical  investigation  of  work  accom- 

**The  importance  of  these  in  their  relation  to  disease  h>as  been  discussed  in 
many  places.  For  a  full  discussion,  see  Industrial  Health  Hazards  and  Occupational 
Diseases  in  Ohio,  by  E.  R.  Hayhurst,  1915. 

*^  See  Hayhurst  report,  cited  above,  p.  118  for  summary  table. 

*«U.  S.  Public  Health  Service,  Public  Health  Bulletin,  No.  76,  p.  10. 

"Hayhurst  report,  cited  above,  p.  36. 

*•  See  U.  S.  Public  Health  Service,  Public  Health  Bulletin,  No.  71,  p.  79. 

«  See  Industrial  Survey  Commission,  Repoit,  Ch.  III.  By  courtesy  of  the  Survey 
Commission  this  Commission  has  had  an  opportunity  to  examine  the  question- 
naires filled  out  by  the  industrial  physicians. 


29 

plished  as  an  index  of  fatigue  showed  in  some  instances  a  smaller  product 
from  the  longer  day  or  longer  week.^^  Finally,  enquiry  of  employees 
brought  most  frequent  complaints  of  fatigue  and  disability  from  those 
working  the  longer  hours. ^^  Hence  the  Commission  recommended  a 
law  limiting  the  employment  of  women  in  most  occupations  to  8.  hours 
per  day  and  48  per  week.^"  The  Commission  reached  its  conclusions 
"Almost  entirely  on  the  basis  of  its  belief  that  its  investigations  show  that 
longer  hours  than  eight  per  day  or  forty-eight  per  week  t^nd  to  produce 
harmful  physiologic,  or  perhaps  it  would  be  better  to  say  pathologic, 
fatigue  in  women  workers.^^ 

The  investigation  to  which  reference  is  made  was  limited  to  the 
work  of  women.  Of  those  reported,  29.2  per  cent  in  Chicago,  and  68.7 
per  cent  outside  of  Chicago  worked  nine  hours  or  more  per  day.  Though 
the  womert  are  under  certain  physical  handicaps  as  compared  to  men, 
there  is  reason  to  believe  that  a  similar  investigation  of  the  hours  of 
employment  of  men  would  have  shown  some  relation  between  hours, 
fatigue  and  health.  That  there  is  a  relation  has  been  indicated  by  in- 
vestigation.^* To  what  extent  the  hours  of  employment  in  Illinois  are 
a  cause  of  ill  health  among  men  this  Commission  is  unable  to  say.  No 
investigation  has  been  made  and  the  (State)  Department  of  Labor  has 
in  recent  years  published  no  data  relating  either  to  hours  of  employment 
or  wages  in  the  State. 

Recognized  and  definitely  established  occupational  diseases  ar6' 
traced  directly  to  their  cause.  The  occupational  factor  in  other  cases 
can  be  established  only  by  records  and  statistical  tabulation.  If  the  re- 
sults of  such  work  are  to  be  properly  used  they  must  be  set  out  in  full 
detail  so  as  to  be  made  comparable  and  sufficient  space  is  not  available 
in  this  report  for  that  purpose.  It  may  be  said,  however,  that  mortality 
statistics  show  higher  death  rates  among  wage-earners  than  among  the 
proprietor  and  professional  classes. ^^  They  show  excesses  of  different 
(fatal)  diseases  in  different  occupations — e.  g.  tuberculosis  among  clerks, 
bookkeepers  and  office  employees;  pneumonia  among  molders,  coal- 
miners,  and  teamsters ;  cirrhosis  of  the  liver  among  saloon-keepers  and 
bar-keepers.^^  They  show,  also,  great  differences  in  death  rates  by 
occupation. ^^  In  view  of  this  fact  the  insurance  companies  writing 
group  life  insurance  take  the  occupational  hazard  into  consideration.^^ 
So  do  the  casualty  and  assessment  companies  in  writing  health  insurance. 
Of  course  persons  in  poor  health  may  be  attracted  to  certain  occupations 
(e.  g.,  the  tuberculous  to  light  office  positions).     To  the  extent  that  this 

^  See  report  cited,  Chi  V. 

^^  See  report  cited,  Ch.  IV. 

52  The  report  and  recommendations  were  signed  by  five  (the  three  physicians 
and  the  two  representatives  of  labor)  of  the  seven  members.  A  minority  report 
was  presented  by  the  two  representatives  of  employers. 

°' Report  cited,  Introduction,  p.  10. 

"  See,  e.  g.,  Reports  by  British  Health  of  Munition  Workers  Committee,  pub- 
lished by  U.  S.  Bureau  of  Labor  Statistics,  Bulletin  230,  especially  pp.  42-70.  It 
has  been  claimed  that  the  8-hour-day  has  been  a  very  important  factor  in  the 
remarkable  reduction  of  the  death  rate  among  members  of  the  Cigar  Makers  Union. 

^  See,  e.  g.,  Pamphlet  on  Consumption  and  Preventable  Diseases  in  American 
Occupations,  by  Ohio  State  Board  of  Health    (1914),  especially  p.   8. 

^^  For  a  valuable  study  of  this  subject,  see  Dublin,  "Causes  of  Death  by  Occu- 
pations," U.  S.  Bureau  of  Labor  Statistics,  Bulletin  207. 

5'  See  "Joint  Mortality  Experience  of  the  Aetna  and  the  Travelers  Insurance 
Companies  on  Group  Policies,"  by  Cammack  and  Morris,  in  Transactions  Actuarial 
Society  of  America,  May  1918,  pp.  29-52. 


30 

is  true  statistics  mislead.  Yet  there  can  be  no  donbt  that  the  conditions 
under  which  men  work  have  an  importance  beyond  the  relation  they  have 
to  recognized  occupational  disease. 

Only  those  gainfully  occupied,  about  two-fifths  of  the  entire  popu- 
lation, are  directly  affected  by  the  working  conditions  described.  All 
are  affected  by  "living  conditions.'^ 

It  is  a  matter  of  common  observation  and  common  knowledge  that 
the  diet  of  most  persons  is  not  as  good  as  their  financial  circumstances 
permit.  Some  of  the  industrial  physicians  and  school  authorities  em- 
phasize the  importance  of  improved  diet  in  relation  to  health  and 
efficiency  in  work  or  study. 

Though  it  has  not  been  accurately  measured,  it  is  generally  pre- 
sumed that  there  is  a  close  relation  between  housing  conditions  and 
disease.  Bad  plumbing,  poor  ventilation,  dirt,  insufficient  light  and 
overcrowding  may  undermine  health  and  spread  disease.  In  the  absence 
of  effective  control  much  of  the  housing  in  Illinois  falls  short  in  these 
respects. 

An  extensive  survey  of  housing  conditions  in  Chicago  has  recently 
been  made  in  connection  with  the  Health  Department's  Tuberculosis 
Survey.^*  The  survey  of  tuberculosis  covered  eight  square  miles  of 
Chicago's  most  congested  territory.  The  Commissioner  of  Health  may 
be  quoted  with  reference  to  the  housing  conditions  found.  In  his 
report^^  it  is  stated,  "In  order  to  arrive  at  some  idea  as  to  the  sanitary 
conditions  of  premises,  reports  were  asked  as  to  plumbing,  ventilation, 
garbage  collection  and  general  cleanliness.  Our  reports  show  that  in 
72.6  per  cent  of  the  13,309  cases  recorded  the  plumbing  was  considered 
good,  in  the  remainder  bad;  in  66.2  per  cent  of  13,937  instances  the 
ventilation  was  indicated  good,  in  the  remainder  bad ;  in  84.3  per  cent  of 
13,604  instances  considered  the  garbage  disposal  was  reported  good,  in 
the  balance  bad;  while  in  63.5  per  cent  of  the  12,913  instances  tabulated 
the  conditions  as  to  general  cleanliness  were  reported  as  good  and  36.4 
per  cent  as  bad." 

An  intensive  survey  of  housing  was  made  to  ascertain  the  relation 
between  housing  and  tuberculosis.  While  no  definite  relation  was  es- 
tablished, numerous  cases  of  insufficient  li^ht  and  air,  and  of  small 
rooms  and  overcrowding  were  found.  The  light  was  reported  as 
*Vretched  in  fully  20  per  cent  of  the  10,100  rooms  where  the  spaces 
were  measured."  A  total  of  43  per  cent  of  the  10,100  rooms  were  found 
to  be  deficient  in  respect  to  the  "amount  of  open  space  that  is  a  part 
of  the  same  lot  on  which  the  house  stands."  In  a  large  proportion  of 
the  cases  the  bedrooms  contained  less  than  80  square  feet,  the  legal 
requirement  since  1910.  Indeed,  of  5,000  measured,  only  34  per  cent 
met  or  exceeded  this  standard;  17  per  cent  had  between  70  and  80 
square  feet;  19  per  cent,  between  60  and  70;  while  28  per  cent  fell  below 
60  square  feet.  In  this  connection  it  is  stated  that  "Few  cities  in 
America  can  show  bedrooms  as  small  as  these  in  Chicago.     It  is  doubt- 

"See  City  of  Chicago  Municipal  Tuberculosis  Sanitarium.  Annual  Report,  1917 
Numerous  other  studies  of  housing?  conditions  have  been  made  in  Chicago  and  other 
cities.     Among  these  reference  may  be  made  to  the  Springfield  Survey   (1914),  and 
Hotismfj  Conditions  in  Chicago,  by  Edith  Abbott  &  S.  P.  Breckinridge 

**' Sanitarium  Report  cited  above,  p.  108. 


31 

ful  whether  any  city  can  show  one-quarter  of  the  number  of  small  bed- 
rooms that,  are  to  be  found  here."^** 

In  a  large  percentage  of  cases  overcrowding  was  found.  The  test 
applied  in  this  case  was  two  persons  per  room.  Though  the  situation 
is  reported  as  better  than  prior  to  1914,  in  3  of  the  22  blocks  more 
than  25  per  cent  of  the  apartments  housed  more  than  2  nersons  per 
room.  In  five  blocks  the  percentages  of  overcrowded  apartments  varied 
from  16  to  25;  in  all  but  one  the  percentage  was  above  8.  Indeed,  in 
one  block  20  per  cent  of  the  apartments  housed  3  or  more  persons  per 
room ;  the  percentage  of  8  other  blocks  ran  from  7.5  to  14.^^  In  a  large 
percentage  of  cases  small  bedrooms  were  occupied  by  3,  4  and  5  or  more 
persons.*'^ 

Other  studies  have  shown  that  this  situation  is  met  with  in  other 
parts  of  Chicago.^^  The  Springfield  Survey  showed  that  that  city  was 
not  without  a  housing  problem.  Hayhurst  reports  that  while  in  one 
or  two  mining  communities  investigated  the  houses  of  the  miners  were 
^'^model  in  regard  to  building  construction  and  arrangement  and  upkeep, 
and  while  the  men  in  a  few  other  communities  are  not  poorly  housed, 
the  great  majority  of  the  mining  centers  present  a  housing  problem."^* 

Bad  water,  bad  milk  and  impure  food,  dirty  streets,  poor  sewage 
disposal,  and  poor  control  of  contagious  diseases  are  important  causes 
of  disease.  Chicago  has  reduced  typhoid  fever  annuo t  lu  the  minimum 
by  introducing  a  good  water  supply  and  treating  the  water  when  neces- 
sary.^^ The  milk  supply  is  pasteurized,  though  at  outside  stations.  In 
many  parts  of  the  State  neither  of  these  necessaries  of  life  has  been 
brought  under  proper  control.  In  most  parts  of  the  State  in  the  ab- 
sence of  proper  medical  inspection  of  school  children  and  quarantine 
regulations,  the  spread  of  contagious  diseases  is  not  properly  protected 
against.  In  fact  except  in  Chicago  and  a  comparatively  few  of  the  other 
health  districts  of  the  State,  sanitation  and  health  administration  are 
sadly  deficient — a  matter  discussed  in  a  later  section  of  this  report.^^ 
Community  neglect  and  high  sickness  and  high  death  rates  go  hand  in 
hand. 

There  is  a  close  relation  between  low  family  incomes  and  sickness 
and  premature  death.  It  has  been  said,  '^the  fact  is  poverty  is  the  great- 
est problem  in  public  health."^''  This  poverty  may  be  due  to  the  dis- 
ruption of  families  by  the  death  or  desertion  of  the  chief  breadwinner, 
to  old  age  or  incapacity,  to  large  families,  to  unemployment,  or  to  low 
wages — as  it  very  frequently  is.  But  whatever  its  cause,  in  the  absence 
of  property  to  fall  back  on,  it  means  inadequate  food,  poor  housing, 
insufficient  clothing,  and  poor  medical  care.  It  means  continuing  at 
work  when  rest  and  recuperation  are  needed.  If  due  to  lack  of  employ- 
ment, this  adds  worry,  nervous  strain  and  perhaps  irregular  living. 

«•  Report  cited  above,  p.  145. 
'1  Report  cited  above,  p.  144. 
"2  Same  reference,  pp.   146-147. 

^  See  Housing  Conditions  in  Chicago,  by  Edith  Abbott  and  S.  P.  Breckinridge. 
"  See  Part  II  of  this  report.  Special  Report,  VI. 
See  "Control  of  Typhoid  Fever  in  Chicago,"  by  Heman  Spalding,  M.  D.,  and 
Tkq^^J^         Bundesen,  M.  D.,  in  American  Journal  of  Public  Health,  May,  1918,  pp. 

^  See  Chapter  II,  below. 
1-     -J^  Si^,?^,?*^  ^"^^"^  Warren  and  Svdenstricker.  "The  Relation  of  Wages  to  the  Pub- 
lic Mealth,     American  Journal  of  Public  Health,  December,  1918,  p.  883. 


32 

Numerous  investigations  have  been  made  of  the  amount  of  sickness 
in  relation  to  family  income  or  wages.  All  of  these  investigations  have 
shown  that  low  wages  and  inadequate  incomes  are  accompanied  by  an 
excessive  amount  of  sickness.  Of  course  the  question  may  be  raised 
whether  the  low  wages  may  not  be  caused  in  many  cases  by  poor  physi- 
cal condition  attended  by  frequent  illness.  The  question  raised  must 
be  answered  in  the  affirmative.  Yet  it  is  true  that  low  wages  and  in- 
adequate incomes  undermine  the  health  of  both  the  worker  and  his  de- 
pendents. 

As  already  indicated,  the  investigations  made  for  this  Commission 
showed  that  there  is  an  excessive  amount  of  sickness  among  the  families 
with  the  smallest  incomes  relative  to  the  need  of  income  to  provide  the 
necessaries  of  life.  Among  the  wage-earning  families  best  off  in  this 
respect  disabling  sickness  occurred  in  63.4  per  100;  among  those  less 
well  off,  in  73.0  per  100;  among  those  least  well  off,  in  76.0  per  100. 
These  results  are  confirmed  by  the  findings  of  other  investigators. 
"Sydenstricker  working  in  the  Pellagra  investigations  of  Goldberger  in 
seven  cotton  mill  villages  in  South  Carolina,  kept  an  accurate  record 
of  all  of  the  cases  of  disabling  sickness  found  among  a  population  of 
4,000  in  May  and  June  of  1916.  A  tabulation  of  these  records  according 
to  family  income  showed  that  among  persons  of  similar  sexes,  ages,  and 
occupations,  the  sickness  rate  per  1,000  varied  from  18.5  in  the  highest 
class  to  70.1  in  the  lowest  income  class.^^®^  An  excessive  number  of  cases 
of  tuberculosis,  anaemia,  and  poor  nutrition  were  found  among  the  most 
poorly  paid  workers  in  the  garment  industry  of  ISTew  York.^^  It  is  stated 
in  the  report  on  Vital  Statistics  made  by  the  "Framingham  Survey," 
that  "the  less  prosperous  districts  (of  the  city)  have  markedly  higher 
death  rates,  and  markedly  higher  rates  from  the  chief  causes  of  mor- 
tality, a  fact  which  indicates  the  importance  of  the  economic  factor  and 
the  need  for  special  effort  in  disease  preventive  work  in  poorer  dis- 
tricts."^° 

The  reports  of  the  Health  Department  of  the  City  of  Chicago 
show  the  greatest  prevalence  of  children's  diseases  and  the  highest  death 
rates  in  the  most  congested  parts  of  the  city  and  where  the  number 
of  families  with  small  incomes  is  relativelv  larare.'^^  The  most  intensive 
investigation  of  children's  diseases  has,  however,  been  made  by  the 
Children's  Bureau  of  the  Department  of  Labor.  Several  investigations 
have  been  made;  and  similar  results  have  been  arrived  at.  The  infant 
mortality  rates  by  fathers'  earnings  may  be  quoted  from  the  Baltimore 
investigations,  the  largest  of  the  several  thus  far  made.''^ 

Inadequate  incomes  undermine  health.  Moreover,  they  may  cause 
persons  of  immature  years  and  mothers  to  enter  employment.  Em- 
ployees of  tender  years  increase  the  sickness  hazard  in  industry.''^  The 
investigations  by  the  Children's  Bureau  have  shown  that  the  gainful 

«•  Warren  and  Sydenstricker,  cited  above,  p.  887. 

«»U.  S.  Public  Healtb  Service,  Publw  Health  Reports,  May  26.  1916. 

'•>  Framin^ham  Health  Demonstration,  Monograph  No.  3,  p.   23. 

"  See  Chapter  II  of  this  report 

"Table  quoted  from  Woodbury.  "Infant  Mortalitv  Studies  of  the  Children's 
Bureau,"  Quarterly  Publications  of  the  American  Statistical  Associatio7i,  June,  1918, 
p.  38.  This  paper  summarizes  a  number  of  the  statistical  investigations  of  the 
Bureau. 

"  See  Hayhurst  Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio, 
p.  8,  et  seq. 


33 


employment  of  mothers,  whether  because  of  the  lure  of  good  wages  or 
because  of  the  necessity  of  assisting  in  the  support  of  the  family,  is  ac- 
companied by  a  higher  sickness  rate  and  a  higher  death  rate  among  in- 
fants, partly  because  of  the  necessity  of  artificial  feeding. 


74 


INFANT  MORTALITY  RATE  BY  FATHERS'   EARNINGS. 


Earnings  of  father. 


Infant  mor- 
tality rate. 


Live  births. 


Deaths. 


All  classes 

Under  $1.50 

$450-1549 

$550-$649 

$650-$849 

$S50-$1,049 

$1,050-$1,249... 
$1,25(}-$1,449... 
$1,450-81 ,849... 
$1,850  and  more 

No  earnings 

Not  reported... 


103.5 

156.7 

118.0 

108.8 

96.0 

71.5 

66.6 

74.0 

86.3 

37.2 

207.7 

140.2 


10,797 

1,544 

1,449 

1,489 

2,417 

1,595 

661 

419 

371 

431 

207 

214 


1,117 

242 

171 

162 

232 

114 

44 

31 

32 

16 

43 

30 


Finally,  the  factor  of  the  individuaFs  behavior  must  be  emphasized 
because  the  violation  of  the  dictates  of  common  sense  in  eating,  drink- 
ing, sleeping,  dress,  recreation,  sexual  relations,  and  much  else  is  of 
frequent  occurrence  and  gives  rise  to  excessive  sickness  and  death  rates. 
That  this  is  true  is  a  matter  of  common  knowledge  and  requires  no 
further  comment. 

(8)  Responsibility  for  Sickness  and  Premature  Death. 

Numerous  causes  of  sickness  and  premature  death  have  been  set 
out  and  commented  on  in  the  preceding  section.  The  analysis  indicates 
something  with  reference  to  responsibility  for  the  problem,  but  it  does 
not  go  far  in  enabling  one  to  measure  the  degree  of  responsibility. 
The  responsibility  must  in  most  cases  be  divided  among  the  individual, 
the  community  and  industry ;  the  share  of  each  is  no  small  one.  Occupa- 
tional diseases  can  be  charged  to  industry;  typhoid  and  contagion  may 
be  charged  to  the  community;  perhaps  the  individual  should  be  charged 
with  responsibility  for  venereal  disease.  Most  diseases,  however,  cannot 
be  traced  to  a  single  definite  source.  The  share  of  the  cooperating 
factors  cannot  be  measured  by  known  methods  of  investigation.  If  it 
could  be  and  low  wages  were  found  to  be  responsible  for  half  the  sick- 
ness, who  could  say  that  low  wages  are  the  fault  of  the  emploj^er,  the 
wage-earner,  or  the  community,  or,  for  that  matter,  are  to  some  extent 
unavoidable  ? 

(9)  The  Prevention  of  Sickness  and  Premature  Death. 

The  data  presented  in  the  preceding  sections  raise  three  related, 
yet  distinct  questions :  ( 1 )  To  what  extent  can  physical  defects  be 
remedied?  (2)  To  what  extent  can  disabling  sickness  be  prevented? 
(3)  To  what  extent  can  death  be  postponed  by  preventing  disease  or  by 
more  successful  treatment  of  illness  Avhen  it  occurs?     This  discussion 

"-See  Infant  Mortality  Studies,  Bulletins  9  and  20. 
—SHI 


34 


of  the  problem  of  sickness  and  death  may  be  closed  with  some  obser- 
vations bearing  upon  these  questions. 

It  is  evident  from  the  data  collected  that  many  wage-earners  and 
many  school  children  have  physical  defects  which  may  impair  their 
efficiency  and  which  frequently  reduce  resistance  to  disabling  disease. 
In  the  opinion  of  industrial  physicians  many  of  the  defects  found  among 
wage-earners,  even  among  those  rejected  for  emplo}Tnent,  may  be 
remedied.  Similarly  many  or  a  large  percentage  of  the  defects  among 
children  can  be  successfully  treated,  the  efficiency  of  the  children  in- 
creased, and  the  seriousness  of  sickness  among  them  in  later  life  reduced. 

Frequently  the  ravages  of  a  disease  are  increasingly  overcome  by 
nature.  The  extent  to  which  we  can  prevent  sickness  depends  upon  our 
knowledge  of  causes  and  our  ability  to  eliminate  or  to  control  them. 
Of  the  possibilities  of  preventing  sickness  and  postponing  death  there  has 
been  much  discussion  in  print' ^  and  at  the  Commission's  hearings  and 
conferences.  Though  estimates  have  been  made  of  the  number  of 
affections  and  of  premature  deaths  which  might  be  avoided,  the  dis- 
cussions are  for  the  greater  number  theoretical,  and  there  is  after  all  a 
great  difference  of  opinion  among  those  medically  trained.  Brend,  in 
a  review  of  what  we  know  about  the  causes  and  the  efforts  to  control  the 
spread  of  many  important  diseases,  questions  much  that  has  been  said 
and  cautions  against  premature  generalization.'^*'  What  is  here  presented 
will  be  limited  to  some  observations  concerning  the  extent  to  which,  in 
the  light  of  experience,  certain  important  diseases  can  be  prevented  or 
their  spread  controlled. 

The  more  important  of  the  "children's  diseases"  may  be  noted  first 
of  all.  In  the  registration  area  in  1916,  32.5  per  cent  of  the  deaths  of 
children  under  10  years  of  age  were  caused  by  measles,  scarlet  fever, 
whooping  cough,  diphtheria,  croup,  poliomyelitis,  and  diarrhoea  and 
enteritis.  In  Illinois  in  1917-18  there  were  perhaps  17,500  cases  of 
measles,  7,500  cases  of  scarlet  fever,  42,000  cases  of  whooping  cough, 
15,000  cases  of  diphtheria,  and  1,600  cases  of  poliomyelitis — nearly  all 
of  them  among  children.^'  With  diphtheria  excepted,  the  only  effective 
control  of  these  diseases  is  by  isolation  of  those  affected  to  prevent  them 
from  spreading  to  others.  In  the  case  of  diphtheria,  antitoxin  has 
reduced  the  death  rate  perhaps  to  a  quarter  of  what  it  was  twenty  years 
ago.  Antitoxin  is  furnished  free  by  the  State  and  is  (and  has  been) 
widely  and  successfully  employed  in  protective  immunization  as  well 
as  in  the  treatment  of  cases.  More  important  as  a  cause  of  death, 
however,  than  all  of  these  communicable  diseases  are  diarrhoea  and 
enteritis.  The  death  rate  from  these,  and  presumably  the  amount  of 
sickness  also,  is  far  above  the  normal  in  Chicago  and  perhaps  in  the  State 
as  a  whole.     There  is  every  reason  to  believe  that  with  more  proper 


T5 


n^  AT^N^^^;  T/TJ  f  V  ^  r^°°S'  ^}^^^^  V^^^y  quoted  discussions  are :  Fisher,  Report 
S.nn^tr«?ron  -^^I'^U'J^^  Y''%1^%.'''',^  ^''''^^''''''i'^'^ ^  Thte  Framingham  Health  De- 
^,c,^^frfV^^  V^^^^^-^^P^^^'t,^^^*^*^^  Examination  Campaigns  j  and  National  In- 
S  PreSfonr^  '  ^^^^^^^^  ^^P°^t  Number  6,  iick^iess  Insurance  orSiSc- 

book  ?nmied'  HeSlf^LTtTr^Ze":'  '""'^  "^""^^  ^"  ^^^  «^^^  «^^  ^^^P*-«  °*  ^'^ 
"  The  Illinois  figures  for  deaths  and  the  estimated  number  of  cases  of  communi- 
cable diseases  are  taken  from  or  based  upon  ratios  found  in  the  report  of  thT  De- 
partment of  Public  Health,  cited  above,  pp.  469  and  487-491  ^^^^^^  ^^  i^^e  ue 


35 

^  feeding  and  better  care  the  number  of  cases  can  be  materially  reduced.'^® 
Of  the  other  diseases  accounting  for  approximately  two-thirds  of  the 
deaths  among  children  many  can  be  likewise  reduced  by  infant  welfare 
work  and  better  care.  Experience  shows  that  a  great  reduction  can  be 
made  in  the  amount  of  sickness  and  the  number  of  deaths  among  children;' 
by  the  application  of  the  knowledge  we  now  have. 

Among  married  women  death  in  child-birth  is  important.  In 
;  Chicago  the  number  of  deaths  per  1,000  births  is  between  5  and  6. 
Experience  shows  that  by  organized  care  the  nuniber  can  be  reduced  to 
less  than  0.5  per  1,000.'^  The  same  conditions  causing  an  excessive 
death  rate  among  parturients  leave  many  other  mothers  disabled  or  in 
such  condition  that  they  become  more  frequently  disabled  from  other 
causes. 

Considering  communicable  diseases  other  than  those  already  men- 
tioned ,  there  were  in  Illinois  in  1917-18  perhaps  more  than  5,800  cases 
of  typhoid  of  which  581  were  fatal.  Typhoid  is  a  most  serious  illness 
and  last  year  (1917-1918)  w^as  responsible  for  0.65  per  cent  of  the 
deaths  in  the  State.  The  death  rate  from  it  in  Chicago  (with  46  cases) 
was  only  1.8  per  100,000  population;  the  corresponding  rate  in  the  rest 
of  the  State  (with  535  cases)  was  14.4.  Preventing  typhoid  is  chiefly 
a  question  of  providing  proper  sanitary  arrangements,  good  water  and 
p  "safe^^  milk,  and  of  controlling  carriers,  and  with  equal  safeguards  the 
disease  should  become  almost  as  infrequent  elsewhere  as  in  Chicago. 
It  can  be  almost  eliminated.     Preventive  inoculation  is  also  efficient. 

Malaria,  w^ith  perhaps  23,000  cases  and  115  deaths,  is  important 
only  in  the  southern  part  of  the  State  and  with  the  application  of  well- 
known  methods  can  be  practically  eradicated. 

With  vaccination  of  many  school  children  and  a  considerable  num- 
ber of  employees  and,  perhaps,  with  a  tendency  toward  immunity  against 
it,  small-pox  has  ceased  to  be  of  much  importance.     It  has  been  brought 
under  effective  control  in  most  parts  of  the  State  so  that  there  were  only 
;  15  deaths  from  it  last  year. 

Tuberculosis  ranks  first  as  a  cause  of  death  in  Illinois:  it  is  esti- 
mated that  there  are  more  than  75,000  active  cases  of  tuberculosis  in 
some  form  or  other  in  the  State.  The  death  rate  from  it  has  decreased 
in  the  more  advanced  countries.  Most  of  this  decrease  took  place  be- 
fore any  campaign  was  made  against  it,  but  there  is  reason  to  believe 
that  a  further  and  very  material  reduction  can  be  effected.^^ 
^  Pneumonia  (always)  and  influenza  (recently)  have  been  among  the 

■  most  important  causes  of  disabling  sickness  and  death.  As  we  have 
seen,  a  generation  has  witnessed  no  decrease  in  the  death  rate  from 
:  pneumonia  in  Chicago,  and  it  would  seem  that  except  by  proper  care  on 
the  part  of  the  individuals  and  isolation  of  those  afflicted  by  it,  very 
-  little  control  can  be  exercised  over  it.  The  ravages  of  influenza  have  at 
times  been  very  great;  it  caused  approximately  1.8  per  cent  of  the  deaths 
in  the  registration  area  in  1916.  During  the  recent  epidemic  the 
amount  expended  in  sickness  benefits  by  some  sickness  funds  increased 

"  See  Chapter  II,  Section  8. 
"  See  Chapter  II,  Section  7. 
**For  a  fuller  discussion  of  this,  see  Chapter  II,  Section  4. 


36 

200  and  even  300  per  cent  over  the  normal  for  autumn  months.  More 
numerous  disabilities  from  other  afflictions  may  be  expected  to  follow  in 
its  train.  Its  cause  is  not  definitely  known,  and  physicians  and  health 
officers  are  experimenting  with  various  methods  of  prevention  and  con- 
trol without  as  yet  obtaining  any  certain  result. 

Venereal  diseases  are  of  frequent  occurrence  among  adults  and  by 
transmission  become  an  important  cause  of  disability  and  death  among 
children.  Syphilis  in  its  later  manifestations  as  in  the  nervous  and 
vascular  systems  ranks  high  as  a  cause  of  death  among  adults.  By 
careful  control  of  vice  and  by  the  reporting  and  treatment  of  cases  there 
is  reason  to  believe  that  a  very  great  reduction,  in  venereal  diseases  can 
be  effected.®^ 

These  diseases,  some  preventable  in  a  large  measure,  others  sub- 
ject to  control  only  within  narrow  limits,  are  important  causes  of  disabil- 
ity. It  would  appear,  however,  that  they  are  responsible  for  only  the 
smaller  part  of  the  sickness  disabilities  among  wage-earners.  Con- 
sidering the  disabilities  among  employed  adults,  of  most  importance  in 
connection  with  some  of  the  problems  the  Commission  has  to  consider 
because  such  disabilities  involve  loss  of  earnings,  reference  may  be  made 
to  the  morbidity  experience  of  a  group  of  establishments  presented 
above.®^  It  cannot  be  said  that  this  experience  covering  twenty  manu- 
facturing plants,  a  sales  force,  and  an  office  force  for  the  years  1915- 
1917,  is  entirely  typical.  The  relative  importance  of  causes  of  dis- 
abling sickness  is  affected  more  or  less  by  the  rejection  of  approximately 
five  per  cent  of  the  applicants  for  work  because  of  affections  of  various 
kinds.  Moreover,  venereal  and  other  diseases  due  to  misconduct  are  not 
compensated,  and  therefore  do  not  appear  in  the  records  of  compensated 
cases  here  used. 

Using  the  morbidity  experience  of  this  group  of  establishments 
as  the  best  available  to  the  Commission,  it  is  to  be  noted  that  measles 
(32  cases),  pneumonia  (180),  tuberculosis  (146),  and  tvphoid  (34), 
account  for  only  392  or  4.76  per  cent  of  the  8,243  disabilities  due  to 
disease  and  lasting  seven  days  or  more  and  compensated  under  the  in- 
surance organization  maintained.  It  is  safe  to  say  that  the  majority  of 
these  and  of  the  1,124  cases  of  disability  due  to  colds  and  grippe  are  not 
preventable  with  known  methods  of  control.  The  "degenerative"  dis- 
eases— cancer,  heart  and  Bright' s  disease,  so  important  as  causes  of  death, 
totaled  200  or  2.4  per  cent  of  the  8,243  cases.  There  were,  also,  236  cases 
of  appendicitis  and  106  cases  of  disabling  hernias,  which,  though  they 
may  be  remediably  treated,  are  not  in  any  large  degree  preventable. 
Second  most  numerous  in  the  list,  with  1,225  or  14.9  per  cent  of  the 
total  of  cases,  are  bronchitis  and  pleurisy  which  have  been  set  down  as 
"doubtfully  preventable."^^  The  largest  -  number  (1,261)  of  cases  of 
disability  were  due  to  rheumatism,®*  some  forms  of  which  are  pre- 
ventable, others  less  subject  to  control.  The  other  cases  specifically 
recorded  included  abcesses,  infections  and  inflammations  (605),  diseases 
of  the  bladder  and  kidneys  (132),  affections  of  the  eye,  ear,  nose  and 

"  See  Chapter  II.   Section   5. 

"  See  above  p.  14    where  the  table  here  commented  on  wiH  be  found. 
~Frammgh-am  Health  Demonstration,  Monograph  No    4    p    21 
»*  "Rheumatism"  as  a  diagnostic  term  is  often  loosely  used  :' many  painful  affec- 
tions of  obscure  character  are  called  "rheumatism."  many  painiui  anec 


37 

throat  (871),  diseases  of  the  stomach  and  intestines  (867),  and  varicose 
veins  and  ulcers  (77) — a  total  of  2,552  or  36.0  per  cent  of  the  7,096 
specifically  recorded.  Most  of  the  ailments  thus  grouped  are  prevent- 
able in  greater  or  lesser  degree. 

For  the  most  part  (tuberculosis  and  diarrhoea  and  enteritis  are 
exceptions)  these  observations  have  been  made  with  the  assumption  of 
no  radical  change  in  working  conditions,  wages,  living  conditions,  and 
personal  hygiene.  Radical  changes  in  these — in  the  environment — might 
be  expected  to  increase  the  power  of  resistance  to  disease  and  to  effect 
a  material  reduction  in  the  number  of  cases  of  disabling  sickness  and 
death.  The  observations  made  are  sufficient  to  indicate  some  of  th^ 
limitations  in  solving  the  problem  of  sickness  by  prevention.  At  the 
same  time  they  indicate  some  of  the  possibilities  of  prevention  which 
will  be  discussed  in  the  next  chapter  of  this  report. 


38 


CHAPTER  II.     COMBATING   DISEASE   AND   CONSERVING 

HEALTH. 


The  analysis  of  the  problem  of  sickness  and  death  and  the  discussion 
*of  the  extent  to  which  these  misfortunes  might  be  prevented  and  efficiency 
maintained  leads  naturally  to  the  question,  What  is  being  done  in  Illi- 
nois to  combat  disease  and  to  conserve  health  ? 

• 

(1)  State  Legislation  Designed  to  Improve  Conditions  and  to  Conserve 
Health, 

The  General  Assembly  in  recent  years  has  enacted  numerous  laws 
designed  "to  improve  the  conditions  under  which  people  Vv^ork,  to  safe- 
guard the  food  and  water  supply,  and  to  improve  conditions  in  lodging 
houses  and  taverns.  Important  among  the  laws  of  the  first  class  are  the 
"Garment  Law"  (1893),  the  Blower  Law  (1897),  the  Structural  Law 
(1907),  and  Health,  Safety,  and  Comfort  Act  (1909,  1915),  the  Occu- 
pational Disease  Act  (1911),  the  Women's  Ten  Hour  Law  (1909,  1911), 
and  the  Wash  House  Law  (1913).  Important  among  the  laws  of  the 
other  classes  are  those  reMting  to  the  inspection,  adulteration  and  serving 
of  food,  the  handling  of  milk,  the  inspection  and  sanitation  of  lodging 
houses  and  taverns,  and  the  prohibition  of  the  use  of  the  common  drink- 
cup.  To  these  should  be  added,  also,  the  law  (1915)  requiring  that  pro- 
vision shall  be  made  for  physical  education  and  training  in  the  schools. 
Inasmuch  as  the  provisions  of  these  laws  are  easily  found  in  two  com- 
pilations—  (Illinois  Department  of  Labor,  General  Information  and 
Laws,  effective  July  1,  1917,  and  Illinois  Department  of  Public  Health, 
General  Information  and  Laws,  effective  July  1,  1917)  it  is  unnecessary 
to  detail  them  here.  The  two  noteworthy  gaps  in  the  legislation  now  in 
effect  are  found  in  the  absence  of  any  state  legislation  relating  to  the 
medical  examination,  nursing  care  and  clinical  treatment  of  school 
children  and  the  absence  of  a  building  code.  Mandatory  or  permissive 
laws  relating  to  the  health  supervision  of  school  children  are  now  found 
in  no  fewer  than  twenty-five  of  the  states.^  Likewise  much  state  legis- 
lation setting  standards  in  the  erection  and  care  of  the  places  in  which 
people  shall  live  has  elsewhere  accompanied  the  setting  of  standards 
with  reference  to  the  conditions  under  which  they  may  ^vork. 

For  reasons  already  stated,  this  Commission  has  not  made  any  inves- 
tigation of  the  administration  and  operation  of  the  legislation  mentioned 
and  now  in  effect  in  this  State.  Reference  is  made  to  it  merely  to  indi- 
cate how  far  legislation  has  been  enacted. 

»  See  Part  II  of  this  report,  Special  Report  XIII,  for  an  analysis  of  this  legis- 
lation and  a  statement  of  the  existing  situation  in  Illinois. 


3^ 

(2)   The  Department  of  Public  Health. 

First  to  be  mentioned  among  agencies  for  the  combating  of  disease 
and  the  conservation  of  health  is  the  State  Department  of  Public  Health. 
Within  the  limits  of  the  powers  conferred  upon  this  department  by 
statute,  it  is  a  well  planned,  well  organized  and  efficient  department  and 
compares  favorably  with  the  better  departments  or  boards  in  other  states. 
Though  handicapped  by  a  comparatively  small  appropriation  ($220,000 
per  year),  it  is  undertaking  an  important  work  in  coordinating  and 
standardizing  the  public  health  service  of  the  State. 

Beginning  only  about  50  years  ago,  state  boards  and  departments  of 
health  have  had  numerous  judicial,  legislative  and  executive  powers  con- 
ferred upon  them  in  an  effort  to  solve  the  problem  of  disease  and  to 
attain  higher  standards  in  public  health  service.  The  former  Board  of 
Health  of  this  State  and  the  present  Department  of  Public  Health  are  no 
exception  to  this  rule.  Yet  a  comparative  analysis  of  legislation  shows 
that  the  tendency  to  centralize  power  in  the  hands  of  this  branch  of  the 
state  machinery  has  proceeded  less  far  in  Illinois  than  in  a  number  of  the 
commonwealths. 

Among  the  general  powers  conferred  and  the  duties  imposed  upon 
the  Department  of  Health  are: 
To  have  general  supervision  of  the  health  and  lives  of  the  people  of 

this  State; 
To  advise  relative  to  public  water  supplies,  water  purification  works, 

sewerage  systems,  and  sewerage  treatment  works; 
To  exercise  supervision  over  water  and  sewerage  nuisances  and  make  and 

enforce  rules  and  regulations  relative  to  the  same; 
To  conduct  sanitary  investigations  when  deemed  necessary  for  the  preser- 
vation and  improvement  of  public  health ; 
To  investigate  nuisances  and  questions  affecting  the  security  of  life  and 

health  in  any  locality  in  the  State ; 
To  maintain  chemical,  bacteriological  and  biological  laboratories; 
To   conduct   examinations   of  milk,   water,   sewage,   wastes   and   other 

substances ; 
To  diagnose  diseases  w^hen  deemed  necessary  for  the  people's  protection; 
To  purchase  and  distribute  to  citizens  of  the   State,  free  of  charge, 

diphtheria   antitoxin,   typhoid   vaccine,   smallpox   vaccine  and   other 

recognized  sera  vaccines  and  prophylactics; 
To  obtain,  collect  and  preserve  useful  information  relative  to  mortality, 

morbidity,  disease  and  health; 
To  investigate  the  causes  of  diseases,  especially  the  causes  of  mortality, 

the  effect  of  localities  and  other  conditions  acting  upon  public  health; 
To  keep  informed  of  the  work  of  local  health  officers  and  agencies; 
To  assist  local  health  authorities  or  agencies  in  the  administration  of 

health  laws; 
To  promote  the  information  of  the  general  public  in  all  health  matters; 
To  enlist  the  cooperation  of  physicians'  organizations  and  other  health 

agencies  in  the  improvement  of  health  and  sanitary  conditions; 


'40 


To  make  sanitary,  sewage,  health,  and  other  inspections  and  examin- 
ations for  the  charitable,  penal  and  reformatory  institutions  and  nor- 
mal schools; 

To  inspect  all  hospitals,  sanitary  and  other  municipal  institutions  and   ^ 
report  their  conditions  and  needs  to  the  authorities  having  juris- 
diction ; 
And  to  print,  publish  and  distribute  documents,  reports,  bulletins,  cer- 
tificates relating  to  the  prevention  of  disease,  health  and  sanitary 
conditions. 

The  Department  also  succeeded  to  the  powers  of  the  former  Board 
of  Health  except  those  relating  to  the  practice  of  medicine,  midwifery 
and  the  regulation  and  examination  of  embalmers,  which  are  now  in- 
cluded in  the  duties  and  powers  of  the  Department  of  Registration  and 
Education.     Among  these  powers  are  those 
To  declare,  enforce,  modify  and  relax  quarantine; 
To  prescribe  rules  and  regulations  for  sanitation; 
To  regulate  transportation  of  the  remains  of  deceased  persons ; 
To  investigate  the  cause  of  dangerously  contagious  or  infectious  diseases, 

especially  when  epidemic; 
To  take  proper  measures  to  suppress  dangerously  contagious  and  in- 
fectious diseases  that  have  become  epidemic  and  when  local  author- 
ities have  refused  or  neglected  to  act  promptly  and  efficiently; 
To  inspect  all  lodging  houses,  boarding  houses,  taverns,  inns  and  hotels 
in  cities  of  100,000  inhabitants  or  more  (Chicago  only)  to  see  that 
the  law  (1899)  relating  to  the  same  is  complied  with; 
To  prescribe  rules  for  the  distribution  and  sale  of  diphtheria  antitoxin ; 
To  care  for  the  registration  of  births  and  deaths; 
To  provide  all  obstetricians  with  a  prophylactic  for  ophthalmia  neona- 

torium ; 
To  formulate  sanitation  rules  for  inns,  hotels,  or  public  lodging  houses; 
To  approve  sanitation  rules  and  regulations  for  barber  shops  adopted  by 

the  Department  of  Registration  and  Education; 
To  prepare  blanks  for  the  reporting  of  occupational  disease ; 
To  select  an  institution  for  the  treatment  of  poor  persons  suffering  from 
rabies.^ 

The  Sanitary  Health  Districts  Act  (1917)  requires,  also,  that  the 
department  shall  conduct  competitive  examinations  for  health  officers 
to  serve  in  such  districts  when  organized. 

Such  are  the  more  important  powers  and  duties  of  the  Department 
of  Public  Health.  It  will  be  noted  that  for  the  greater  part  they  are 
investigative  and  advisory  in  so  far  as  sanitary  matters  and  the  personnel 
of  the  local  health  administration  are  concerned.  It  has  supervision 
over  water  and  sewerage  nuisances  and  is  to  advise  relative  to  public 
water  supplies,  water  purification  works,  sewerage  systems,  and  sewerage 
treatment  works;  unlike  the  corresponding  departments  of  Wisconsin, 
Ohio  and  fifteen  other  states,  it  is  not  vested  with  power  of  approval  of 
plans  for  water  and  sewerage  systems.     In  New  Jersey  and  New  York 

» For  the  above,  see  Illinois  Department  of  Public  Health ;  General  Information 
and  Laws,  effective  July  1,  1917. 


41 

the  corresponding  departments  are  empowered  to  determine  the  qualifi- 
cations of  local  health  officers  for  appointment;  in  several  states  the 
appointment  of  local  health  officers  is  vested  in  the  State  Board  of 
Health;  in  several  states  local  health  officers  may  be  removed  by  the 
State  Board;  in  Ohio  appointments  of  health  officers  in  villages  must 
be  approved  by  the  State  Board  of  Health;  a  good  share  of  the  local 
health  work  in  Pennsylvania  is  done  by  representatives  of  the  State 
Board;  but  in  Illinois  the  Department  of  Public  Health  has  no  clearly 
defined  authority  in  local  health  administration  except  in  epidemics; 
it  has  nothing  to  do  with  the  appointment  or  removal  of  local  health 
officers  except  under  the  act  of  1917  relating  to  the  formation  of  a  new 
type  of  public  health  district,  where  it  is  to  hold  examinations  and  certify 
a  list  of  eligibles  from  which  the  health  officer  of  any  such  district  is  to  be 
selected.^ 

For  doing  its  work  the  Department  of  Public  Health  has  organized 
ten  divisions  besides  the  executive,  and  to  assist  in  the  control  of  com- 
municable diseases  and  serve  in  an  advisory  capacity  to  local  health 
officers  it  has  established  six  health  districts  with  a  full-time  health 
officer  in  each.  An  enumeration  of  these  several  divisions  (the  execu- 
tive excluded)  will  indicate  the  varied  activities  of  the  Deparlment. 

(1)  The  Division  of  Communicable  Diseases; 

(2)  The  Division  of  Tuberculosis; 

(3)  The  Division  of  Sanitation; 

(4)  The  Division  of  Vital  Statistics; 

(5)  The  Division  of  Child  Hygiene  and  Public  Health  Nursing; 

(6)  The  Division  of  Sarvqiys  and  Bjural  Hygiene; 

(7)  The  Division  of  Diagnostic  Laboratories  (with  a  central  labora- 
tory at  Springfield  and  six  branch  laboratories  in  different  parts  of  the 
State) ;  ■  1  '  ^  -^|  g^ 

(8)  The  Division  of  Hotel  and  Lodging  House  Inspection; 

(9)  The  Division  of  Public  Health  Instruction; 

(10)  The  Division  of  Social  Hygiene  (for  the  control  of  venereal 
disease). 

The  work  of  these  several  divisions  has  recently  been  set  forth  in  the 
report  of  the  Department  to  the  Governor  and  does  not  require  pre- 
sentation in  detail  here.  Among  the  important  accomplishments  of  the 
Department  are  these: 

(1)  The  issuing  of  rules  for  the  reporting  of  open  cases  of  tubercu- 
losis by  attending  physicians  and  of  venereal  disease  by  attending 
physicians  and  druggists ;  the  promulgation  of  rules  for  the  control  of  the 
tuberculous  and  the  inauguration  of  a  system  of  treatment  of  women  of 
ill-repute  afflicted  by  venereal  disease  at  the  expense  of  the  counties  in 
which  they  are  arrested; 

(2)  The  reorganization  of  the  system  for  the  recording  of  deaths 
so  that  the  State  has  been  added  to  the  (census)  registration  area  for 
deaths ; 

'  Data  for  other  states  have  been  taken  from  A  Report  on  State  Public  Health 
Work — Based  on  a  Survey  of  State  Boards  of  Health,  by  Charles  V.  Chapin,  M.  D. 
This  survey  was  made  under  the  direction  of  the  Council  on  Health  and  Public 
Instruction  of  the  American  Medical  Association,  1916. 


4^ 

(3)  The  securing  of  fuller  reports  of  communicable  disease.  In 
this  connection  it  must  be  noted  that  many  practitioners  fail  to  report 
all  cases  of  communicable  disease  attended  by  them.  The  complete 
reporting  of  deaths  and  of  communicable  diseases  is  as  important  in 
public  health  work  as  good  accounting  is  in  the  conduct  of  a  business. 
Without  it  the  necessary  basis  for  a  successful  combating  of  disease 
cannot  be  obtained ; 

(4)  The  fuller  reporting  of  births.  Unfortunately  the  failure  of 
many  physicians,  midwives,  and  other  attendants  to  report  births  fully 
has  prevented  the  State  from  being  added  to  the  registration  area  for 
births  and  has  not  given  the  best  basis  for  infant  welfare  work  and 
improved  maternity  care; 

(5)  The  provision  without  charge  (through  some  500  stations) 
of  vaccine  for  typhoid  fever  and  of  antitoxin  for  diphtheria; 

(6)  The  establishment  in  eleven  cities  of  clinics  for  the  effective 
treatment  of  crippled  children,  chiefly  as  a  result  of  "infantile  paralysis," 
these  clinics  resulting  in  the  rehabilitation  of  many  children  who  other- 
wise would  remain  handicapped  for  life; 

(7)  The  making  of  a  number  of  sanitary  surveys  (in  Freeport, 
Kockford,  Waukegan,  and  elsewhere),  of  great  importance  in  the  de- 
velopment of  good  standards  in  the  public  health  service; 

(8)  A  very  effective  educational  campaign  against  disease  and  for 
good  public  health  service  through  the  Illinois  Health  News  (monthly 
publication  of  the  Department),  leaflets,  the  press,  by  exhibits,  etc.; 

(9)  The  establishment  of  a  course  for  the  training  of  public  health 
nurses; 

(10)  And  the  coordination  of  the  public  health  and  medical  forces 
of  the  State  in  the  control  of  contagious  diseases,  well  illustrated  in  the 
recent  epidemic  of  influenza  which  revealed  the  weakness  and  inadequacy 
of  the  local  forces  in  combating  disease  in  most  parts  of  the  State. 

Modern  conditions  call  for  a  strong  and  liberally  supported  state 
department  of  public  health  if  disease  is  to  be  efficiently  combated  and 
health  conserved.  They  call  also  for  much  more  as  a  summary  discussion 
of  local  health  administration  will  show. 

(3)  Local  Health  Admmistration. 

Most  of  the  work  involved  in  combating  disease  and  safe-guarding 
health  is  left,  officially,  to  the  local  authorities.  Of  these  there  are  about 
1,100  in  the  State.  In  other  words  the  102  counties  contain  no  fewer 
than  1,100  independent  health  districts.  Some  of  these  are  townships, 
some  are  counties,  some  are  incorporated  villages  with  small  populations, 
and  a  comparatively  few  are  cities  large  enough  to  support  an  efficient 
health  administration. 

Under  the  Cities  and  Villages  Act,  the  city  council  in  cities  and  the 
board  of  trustees  in  villages  have  power  to  appoint  a  board  of  health  and 
prescribe  its  duties  and  powers.  In  cities  under  the  commission  form 
of  government  the  statute  provides  for  a  department  of  public  health  and 


43 

safety,  administered  b}^  a  commissioner,  whose  duties  are  prescribed  by 
ordinance  in  the  same  manner  as  in  other  cases.^ 

The  county  commissioners  in  counties  without  township  organization 
and  the  supervisor,  assessor  and  town  clerk  of  every  town  in  counties 
under  township  organization,  are  constituted  boards  of  health  with 
powers  and  duties  extending  over  the  territory  not  included  within  the 
corporate  limits  of  any  city  or  village.  If  there  is  an  outbreak  of  any 
dangerously  communicable  disease,  it  becomes  the  duty  of  any  such  board 
of  health  to  make  and  enforce  such  rules  and  regulations  as  may  be 
necessary  to  check  the  spread  of  the  disease.  It  has  power  to  make  and 
enforce  quarantine  rules  and  to  require  disinfection  in  case  of  contagious 
disease.  It  has  powers  and  duties,  generally,  "to  do  all  acts,  make  all 
regulations  which  may  be  necessary  or  expedient  for  the  promotion  of 
health  or  the  suppression  of  disease,"  "to  appoint  physicians  as  health 
officers  and  prescribe  their  duties,^'  "to  incur  the  expenses  necessary  for 
the  performance  of  the  duties  and  powers  enjoined  upon  the  board," 
"to  provide  gratuitous  vaccination  and  disinfection,"  and  "to  require 
reports  of  dangerously  communicable  diseases."  For  each  day  spent  in 
the  performance  of  their  duties  in  this  connection  each  member  of  the 
board  is  allowed  $1.50  together  with  all  bills  contracted  and  all  sums  of 
money  expended.^ 

This  basic  legislation  has  not  operated  efficiently  in  the  villages  and 
smaller  cities,  and  in  the  territory  outside  of  incorporated  places.  Feel- 
ing the  need  for  a  better  organization  the  last  General  Assembly,  upon 
the  recommendation  of  the  Department  of  Public  Health,  enacted  a  laAV 
relating  to  the  "organization  of  public  health  districts  and  for  the  estab- 
lishment and  maintenance  of  a  health  department  for  the  same."^ 

Under  this  Public  Health  District  law  "any  town,  or  two  or  more 
adjacent  towns  in  counties  under  township  organization,  or  any  road 
district,  or  two  or  more  road  districts  in  counties  not  under  township 
organization,  or  any  town  or  towns  in  a  county  under  township  organ- 
ization and  an  adjacent  road  district  or  road  districts  in  a  county  not 
under  township  organization"  may  after  petition  signed  by  not  less  than 
five  per  cent  of  the  voters  voting  at  any  election  and  upon  the  affirmative 
vote  by  a  majority  of  those  voting  upon  the  question  (in  each  minor 
political  division  involved),  be  organized  into  a  public  health  district. 
If  such  a  district  is  organized  it  has  certain  powers  conferred  upon  it 
and  is  under  the  necessity  of  following  certain  standards  set  up  in  the  law. 

In  counties  not  under  township  organization  the  county  com- 
missioners serve  as  the  board  of  health  for  each  public  health  district  in 
the  county.  Where  a  public  health  district,  in  counties  under  township 
organization,  consists  of  a  single  town,  the  supervisor,  assessor  and  town 
clerk  of  such  town  serve  as  the  board  of  health.  Where  the  district  con- 
sists of  two  or  more  adjacent  towns,  the  supervisors  and  the  chairman  of 
the  county  board  serve  in  that  capacity.  Finally,  where  a  public  health 
district  consists  of  a  town  or  towns  in  a  county  under  township  organ- 

*  Illinois  Department  of  Public  Health,  General  Information  and  Laws.  Effec- 
tive July  1,  1917,  Section  40. 

'Reference  cited  above,  sections  34-38. 

8  Law  filed  June  26,  in  force  July  1,  1917.  Laws  of  1917,  p.  763.  Found  in 
reference  above  cited,  sections  41-60. 


44 

ization  united  with  a  road  district  or  road  districts  in  a  county  not  under 
township  organization,  the  supervisor  or  supervisors  of  the  town  or  towns, 
together  with  the  road  district  clerk  or  road  district  clerks,  shall  be  the 
board  of  health  for  such  public  health  district. 

When  organized  such  a  public  health  district  has  power  to  levy  a 
"public  health  tax''  of  not  to  exceed  4  mills  on  each  dollar  of  taxable 
property  within  the  district,  over  and  above  all  other  taxes,  now  or  which 
may  be  authorized,  the  taxes,  when  collected,  to  constitute  a  "public 
health  fund."  The  board  is  empowered,  also,  to  appoint  a  public  health 
officer,  and  with  his  advice  and  approval  such  nurses,  chemists,  experts, 
clerks,  and  assistants  as  the  public  health  officer  may  deem  necessary. 
It  is,  moreover,  empowered  to  equip  and  maintain  suitable  offices,  facil- 
ities and  appliances  and  to  establish,  equip  and  maintain  an  analytical, 
biological  and  research  laboratory.  The  health  officer,  be  it  noted,  must 
be  appointed  from  a  list  of  eligibles  supplied  by  the  State  Department 
of  Public  Health,  shall  devote  all  of  his  time  to  his  official  duties,  and 
shall  be  paid  an  annual  salary  of  not  less  than  $1,500.  He  is  the  execu- 
tive officer  of  the  district  and  shall  make  all  necessary  inspections  and 
enforce  all  health  and  sanitary  regulations  in  force  in  it. 

This  act  has  made  an  improved  local  health  administration  possible. 
The  act  is,  however,  permissive,  not  mandatory,  and  no  health  districts 
have  as  yet  been  formed  under  it.'^  Interest  in  the  War,  lack  of  interest 
in  public  health,  the  necessity  of  holding  an  election,  an  interpretation 
of  the  law  requiring  the  signing  of  the  necessary  petition  to  be  by  five 
per  cent  of  the  number  voting  at  the  election  at  which  the  largest  vote 
was  cast,  and  the  addition  of  a  special  tax  if  a  health  district  is  created 
have  stood  in  the  way.  It  is  unlikely  that  the  permissive  legislation  will 
be  effective. 

This  is  the  description  of  local  health  administration  from  a  legal 
point  of  view.  From  a  practical  point  of  view  it  can  be  said  to  be  largely 
an  incidental  matter  in  local  government,  for  most  of  those  assuming 
responsibility  under  the  law  assume  it  because  they  have  been  selected 
for  and  serve  in  some  other  office. 

It  has  been  said  that  "public  health  is  purchasable  and  (in  so  far 
as  it  depends  upon  public  health  administration  and  sanitation)  the 
community  may  have  as  much  health  or  as  little  health  as  the  people  are 
willing  to  pay  for."  In  Chicago  and  a  small  minority  of  other  health 
districts  a  good  deal  has  been  spent  on  health  administration  and  with 
good  result.  For  many  years  the  Chicago  Health  Department  has  com- 
pared favorably  with  the  health  departments  of  other  large  cities.  In 
most  parts  of  the  State,  with  fully  half  of  the  population,  little  has  been 
spent  and  inefficient  health  administration  has  been  the  result. .  The  one 
point  on  which  there  was  general  agreement  among  those  who  testified 
at  the  Commission's  public  hearings  was  that  as  a  general  rule  local 
health  administration  is  lamentably  weak  and  ineffective.  All  agreed 
that  something  should  be  done  to  improve  it  and  to  place  it  upon  an 
efficient  basis. 

^  LaSalle  and  two  neighboring  towns  have  a  joint  arrangement  in  health 
matters.  This  was  entered  into  before  the  Public  Health  District  Law  was  enacted 
and  is  independent  of  it.  Steps  are  now  being  taken,  in  at  least  three  localities,  to 
hold  elections  to  determine  whether  health  districts  shall  be  organized. 


45 


The  two  important  reasons  why  local  public  health  administration 
in  Illinois  is  generally  weak  are:  (1)  most  of  the  health  districts  are 
too  small  and  have  too  little  taxable  property  to  support  an  efficient 
service;  (2)  other  matters  have  made  a  stronger  appeal  to  the  citizens 
and  to  those  who  have  directed  local  affairs.  In  other  words,  a  bad 
organic  law  and  a  lack  of  appreciation  of  public  health  matters — not  men 
in  health  offices — must  bear  the  greater  share  of  the  responsibility  for 
the  situation  that  exists. 

But  wherever  the  responsibility  may  rest,  in  Illinois  as  in  most  other 
states,  little  has  been  paid  out  of  the  public  funds  for  health  and  sani- 
tation. Data  are  now  being  collected  by  the  State  Department  of  Public 
Health  relating  to  this  and  to  other  matters,  but,  unfortunately,  they 
have  thus  far  been  obtained  from  too  few  districts  to  show  just  what  is 
being  spent  in  the  State  as  a  whole.  In  the  absence  of  better  data  those 
contained  in  the  following  table  are  presented.  The  sums  entered  are 
for  the  conservation  of  health  and  sanitation  and  include  not  only  the 
amounts  spent  for  local  health  administration  but  also  the  amounts  spent 
for  care  of  sewers,  street  cleaning,  etc.^  The  data  are  taken  from  the 
Census  report  on  Wealth,  Debt,  and  Taxation,  and  are  for  the  year  1913.'' 

EXPENDITURES    OF    URBAN    COMMUNITIES    IN    ILLINOIS    FOR    HEALTH 

AND    SANITATION,    1913. 


Groups  of  cities 
and  towns. 


Total 

Average 

Expendi- 

Popula- 

govern- 

fper 

tures  on 

tion 

mental 

capita 

health 

of 

cost  pay- 

of cost 

and 

group. 

ments  of 

pay- 

sanita- 

group. 

ments. 

tion. 

Average 

Percent 

per  capita 

of  total 

expended 

expended 

for  health 

on  health 

and 

and 

sanitation. 

sanitation. 

Minimum 

and 
maximum 
main  sums 
per  capita 
spent  for 
health  and 
sanitation. 


Chicago 

Nine  cities,  popula 
tions  of  30,000  and 
over 

Twenty-eight  cities, 
populations  of  8,000 
to  30,000 

Ninety-seven  towns 
populations  2,500  to 
8,000 , 


2,344,018 

$62,031,418 

$26.46 

$4,258,053 

$1.82 

6.9 

415, 757 

8,639,435 

20.78 

353, 336 

.85 

4.1 

525,826 

9,059,859 

17.23 

294,598 

.56 

3.2 

413,534 

6,895,350 

16.67 

90,582 

.22 

1.3 

$.38 

and 

1.77 

0 

and 

.84 


In  1913,  according  to  the  Census,  the  urban  communities  of  Illi- 
nois with  populations  of  2,500  and  over  spent  $87,363,536,  of  which 
$4,984,097  or  5.7  per  cent  was  for  health  and  sanitation.  They  spent 
on  police,  fire  and  related  departments  (for  "protection  of  person  and 

*  The  items  included  are  shown  by  the  Census  definition  of  two  groups  of  outlays 
reported  separately  for  only  such  cities  as  have  a  population  of  30,000  or  over: 

(a)  '^Expenses  for  conservation  of  health. — Under  this  title  are  included  the  ex- 
penses connected  with  the  general  conduct  of  the  health  department,  the  prevention 
and  treatment  of  communicable  diseases,  the  conservation  of  child  life,  including 
medical  work  for  school  children,   and  food  regulation  and  inspection." 

(b)  '^ Expenses  for  sanitation. — Expenses  for  sanitation,  or  promotion  of  clean- 
liness, include  those  for  the  care  and  maintenance  of  sewers  and  for  the  disposal  of 
sewage,  the  collection  and  disposal  of  refuse,  including  the  cleaning  of  streets,  the 
operation  of  public  laundries,  washhouses,  and  convenience  stations,  the  prevention 
of  smoke,  and  other  measures  such  as  are  employed  by  cities  in  securing  sanitary 
conditions. 

^  Table  compiled  from  U.  S.  Census,  Wealth,  Debt  and  Taxation,  Vol.  II,  pp. 
582-586. 


46 

property")  $13,375,024,  or  almost  2.7  times  as  much  as  for  health  and 
sanitation.  The  more  recent  data  available  in  census  publications  indi- 
cate that  while  the  outlavs  have  increased,  there  has  been  no  substantial 
change  in  the  relative  figures  here  presented. 

In  presenting  these  figures  it  should  be  clearly  stated  that  Illinois  is 
not  exceptional  in  respect  to  the  small  outlays  for  health  and  sanitation. 
As  against  the  $1.34  spent  for  health  and  sanitation  by  incorporated 
places  here,  New  York  in  1910  spent  $2.11;  Massachusetts,  $1.78;  Cali- 
fornia, $1.36;  Wisconsin,  $1.30;  Ohio  and  Colorado,  $1.17;  Michigan, 
$1.11;  Pennsylvania,  $1.00;  Minnesota,  $.93;  Indiana,  $.74;  Iowa,  $.57; 
Kansas,  $.48.  These  comparisons  are  not  unfair  for  the  figures  in  all 
cases  are  the  average  outlay  for  the  populations  of  incorporated  places 
of  2,500  and  over. 

Some  students  of  public  health  administration  have  maintained  that 
.  in  a  city  of  20,000  the  outlays  required  for  the  proper  conservation  of 
health  will  be  about  $1.00  per  capita  per  year.  Larger  cities  require 
more  than  $1  per  capita;  smaller  places  can  give  equivalent  service  for 
somewhat  less.  It  will  be  noted  in  the  above  table  that  while  Chicago 
spent  $1.82  per  capita,  the  nine  cities  other  than  Chicago  with  popu- 
lations of  30,000  or  over,  spent  85  cents,  the  smaller  cities  with  8,000 
to  30,000,  56  cents,  the  smallest  cities  and  towns,  22  cents.  This  was  for 
both  the  conservation  of  health  and  sanitation.  Were  data  available  for 
the  health  districts  outside  of  incorporated  places  the  showing  would  be 
worse  still. 

The  table  gives  the  minimum  and  the  maximum  figures  for  each 
group  of  incorporated  places.  Of  course  great  differences  between  places 
are  found.  The  details  presented  by  the  Census  show  that  one  city  with 
a  population  of  more  than  35,000,  14  cities  with  populations  of  8,000  to 
30,000,  and  78  smaller  incorporated  places,  spent  less  than  40  cents  per 
capita.  Indeed  one  city  with  a  population  of  more  than  17,000  spent 
just  10  cents  per  capita,  while  41  of  the  smallest  towns  and  cities  spent 
less  than  that  sum. 

The  census  report  on  Financial  Statistics  of  Cities  for  1917  contains 
the  following  figures  for  Illinois  cities  with  populations  of  30,000  or  over. 
Unfortunately  corresponding  data  are  not  available  for  smaller  places. 

EXPENDITURES  OF  ILLINOIS  CITIES,   1917. 


City. 


Expenditures 

for  conservation  of 

health. 


Amount. 


Per  capita. 


Expenditures 

for 

sanitation. 


Amount. 


Per  capita. 


Chicago 

East  St.  Louis 

Peoria 

Springfield.... 

Rockford 

Decatur 

Joliet 

Quincy 

Aurora 

Danville 


$1,487,874 

$0.60 

$4,913,491 

7,325 

.10 

69,203 

24,106 

.34 

72,745 

8,025 

.13 

51,682 

19,109 

.35 

45,982 

6,121 

.15 

19,906 

3,120 

.08 

36,716 

1,081 

.03 

18,339 

4,569 

.13 

34,507 

2,428 

.07 

17,184 

$1.97 
.93 

1.02 
.84 
.83 
.50 
.97 
.50 

1.01 
.53 


47 

The  average  per  capita  outlays  for  all  cities  of  the  United  States 
in  the  group  with  East  St.  Louis,  Peoria,  Springfield,  and  Eockford 
were  $.29  and  $1.15  for  health  and  sanitation  respectively.  The  corres- 
ponding averages  for  cities  of  the  next  lower  group  containing  Decatur, 
Joliet,  Quincy,  Aurora  and  Danville,  were  $.31  and  $1.00. 

What  these  sums,  especially  when  combined  with  the  small  health 
districts  which  so  widely  obtain,  mean  in  terms  of  service  those  versed 
in  health  administration  and  sanitation  will  know.  The  following 
tabular  statement  of  the  answers  from  343  health  departments  which 
had  recently  reported  to  the  State  Department  of  Public  Health  shows 
clearly  the  short-comings  in  local  health  legislation  and  administration.^*^ 


Item  number. 


Population  of  places  reporting. 


20,000 
and  over.* 


5,000 
to  20,000. 


1,000 
to  5,000. 


1,000 
and  less. 


Number  of  cities  reporting 

Having  annual  appropriations  for  health  work 

Having  health  officers 

Having  full  time  health  officers 

Having  medical  health  officers 

Health  officers  receiving  salary 

Cities  having  nursing  service 

Doing  public  child  hygiene  work 

Having  welfare  stations 

In  which  health  officer  is  registrar 

Campaigns  made  for  complete  reports 

Public  sewerage  system 

Public  garbage  collection 

Special  tax  levied  for  garbage 

Having  manure  ordinance 

Having  public  water  supply 

Water  regularly  examined 

Water  treated 

Water  considered  safe 

Having  plumbing  inspector 

Having  full  time  plumbing  inspector 

Having  building  code 

Having  privy  ordinance 

Venereal  diseases  reported 

Venereal  diseases  dispensary 

Regular  food  inspection 

Food  conditions  satisfactory 

Regular  dairy  inspection 

Dairy  conditions  satisfactory 

Communicable  disease  ordinances 

Communicable  disease  reports  complete 

Having  laboratory 

Epidemiological  investigations  made 

Cards  used 

Instructions  given 

Practicing  fumigation 

Expense  of  fumigation  defrayed  by  city. . . 


12 

38 

122 

11 

25 

34 

12 

38 

93 

6 

2 

0 

9 

29 

56 

12 

0 

0 

4 

5 

1 

4 

4 

0 

7 

3 

0 

7 

7 

11 

10 

30 

61 

12 

36 

53 

8 

17 

12 

4 

11 

9 

12 

29 

65 

12 

38 

75 

10 

20 

5 

8 

15 

7 

12 

32 

72 

11 

20 

26 

9 

7 

8 

10 

10 

25 

10 

34 

72 

4 

15 

26 

3 

0 

0 

5 

10 

3 

6 

24 

74 

10 

17 

4 

6 

27 

75 

12 

34 

88 

9 

31 

58 

6 

2 

0 

10 

14 

24 

8 

8 

14 

12 

36 

101 

12 

38 

121 

12 

34 

92 

171 

22 

104 

0 

74 

0 

0 

0 

0 

21 

81 

17 

7 

1 

71 

24 

0 

0 

27 

1 

0 

i 

74 

52 

0 

0 

121 

0 

106 

92 

78 

0 

33 

19 

136 

165 

125 


•  The  city  of  Chiicago  is  not  included. 

Health  problems  will  not  take  care  of  themselves.  Not  only  must  there 
be  a  health  officer,  but  it  is  agreed  that  he  must  he  a  full-time,  well- 
trained,  properly  remunerated  officer  with  tenure  in  harmony  with  the 
spirit  of  civil  service  rules.  A  considerable  number  of  the  smaller  places 
reporting  have  no  regular  health  officers;  only  half  of  the  larger  cities, 
only  2  of  the  38  cities  in  the  5,000  to  20,000  group,  and  none  of  the 
smaller  cities  have  a  full-time  officer.  The  fact  is  that  most  of  the  smaller 


"  The  Health  Insurance  Commission  is  indebted  to  the  Department  of  Public 
Health  for  these  and  much  other  data. 


48 

places  could  not  afford  to  hire  a  full-time  officer  worth  hiring.  It  can 
be  taken  for  granted  that  seldom  do  the  officers  not  medically  trained, 
have  any  special  training  for  the  work  they  are  presumed  to  do.  Only 
9  of  12  health  officers  in  the  largest  cities,  only  29  of  38  in  the  next 
largest  cities,  only  58  of  93  in  the  towns  and  cities  with  populations  of 
from  1,000  to  5,000,  and  only  74  of  104  in  the  smallest  places,  reported 
themselves  as  medically,  trained.  Put  in  other  words,  only  in  two  cases 
in  three  is  the  health  officer  medically  trained,  and  in  only  one  case  in 
thirty  does  he,  whether  trained  or  untrained,  devote  his  full  time  to  his 
office.  Or,  put  in  still  other  words,  in  the  smaller  health  districts  there 
is  no  health  officer  at  all,  or  a  policeman  or  some  one  else  who  serves 
incidentally,  or  a  doctor  whose  service  is  incidental  to  his  private  practice. 
In  the  larger  places  the  health  officer  is  most  frequently  a  doctor  engaged 
for  the  greater  part  of  his  time  in  taking  care  of  his  private  practice. 
Seldom  are  appointments  and  tenure  in  harmony  with  the  spirit  of  our 
civil  service  laws. 

Comment  on  most  of  the  things  shown  by  this  tabular  statement  is 
unnecessary — the  limited  public  health  nursing  service;  the  limited 
amount  of  public  child  hygiene  work;  the  limited  number  of  child  wel- 
fare stations;  the  large  number  of  places  in  which  no  campaign  has 
been  made  to  secure  complete  reporting  of  births  and  deaths ;  the  number 
of  cities  without  a  public  sewerage  system ;  the  exceptional  cases  in  which 
public  provision  is  made  for  the  disposal  of  garbage;  the  limited  extent 
to  which  the  right  has  been  exercised  to  levy  a  special,  tax  for  garbage 
collection  and  disposal;  the  many  places  with  no  ordinance  relating  to 
the  disposal  of  manure;  the  neglect  of  water,  which  frequently  cannot 
be  reported  safe;  the  infrequent  building  codes;  the  frequent  absence 
of  regulations  relative  to  privies;  the  fairly  general  failure  to  inspect 
dairies  with  the  result  that  conditions  in  dairies  are  frequently  un- 
satisfactory or  bad;  the  frequent  failure  to  report  communicable  dis- 
eases fully;  the  general  absence  of  laboratories  for  health  work;  and 
the  shortcomings  in  placarding  contagious  diseases  and  the  occasional 
failure  reported  to  make  sanitary  the  places  in  which  these  contagious 
diseases  have  occurred. 

In  view  of  what  has  been  said  the  following  summary  of  a  survey 
of  a  large  number  of  mining  towns  will  occasion  no  surprise: 

"Many  mining  towns  are  unincorporated.  Often  there  is  no  health 
officer.  The  board  of  health  consists  of  the  mayor  and  two  or  more 
members  of  the  council  in  the  larger  (incorporated)  towns.  In  many 
cases  only  the  township  supervisor's  arrangement  prevails.  Very  often 
the  health  officer  is  not  a  physician  and  is  entirely  unskilled  in  matters 
of  hygiene  and  sanitation.  Very  often  he  belongs  to  the  old  type  of 
health  officer,  who  lays  stress  on  rubbage,  ash-dumps,  foul  smells,  and 
fumigation,  but  pays  little  attention  to  wells,  privies,  screening,  milk 
supply,  or  the  prompt  isolation  and  concurrent  disinfection  of  a  case  of 
communicable  disease. 

"The  public  health  protection  as  afforded  in  98  per  cent  of  the  towns 
visited  was  found  to  be  very  unsatisfactory.  The  methods  of  handling 
communicable  diseases  are  old  and  not  in  accord  with  modern  methods. 


49 

In  some  communities  persons  quarantined  were  required  to  pay  for 
fumigation     *     *     * 

"A  large  per  cent  of  the  towns  visited  were  without  sewers  and  con- 
sequently privies  were  the  common  method  of  excreta  disposal.  Shallow 
wells  were  also  in  use."^^ 

The  sanitary  surveys  thus  far  made  show  that  this  situation  is  by 
no  means  limited  to  mining  towns.  Sanitary  surveys  show  extensive 
problems  in  rural  communities;  they  show  also  extensive  problems  in 
some  of  the  cities  of  second  rank  in  population. 

(4)   The  Campaign  Against  Tuberculosis. 

No  campaign  for  the  prevention  of  disease  can  be  complete  that 
does  not  include  a  well  developed  plan  for  locating,  controlling  and  pre- 
venting the  spread  of  tuberculosis. 

Tuberculosis  in  1917-18  ranked  first  among  diseases  of  major  sani- 
tary importance,  as  a  cause  of  death  in  Illinois.^^  In  the  United  States 
as  a  whole  the  Census  Mortality  Statistics  show  that  in  1916  tuberculosis 
was  the  cause  of  death  in  1  case  in  10  (10.1  per  cent). 

Pulmonary  tuberculosis  has  its  greatest  incidence  among  adults 
between  the  ages  of  21  and  45.  In  view  of  this  fact  it  is  not  surprising 
that  5.37  per  cent  of  the  young  men  rejected  in  the  first  draft  were  re- 
jected because  tuberculous.  This  was  about  1.56  per  cent  of  all  who 
were  examined. 

In  the  Framingham  Community  Health  and  Tuberculosis  Survey  a 
special  effort  has  been  made  to  ascertain  how  many  are  afflicted  with 
tuberculosis  in  its  different  forms.  Of  4,473  carefully  examined  in 
Framingham,  96  or  2.14  per  cent  were  found  to  be  tuberculous.  It  was 
found,  moreover,  that  there  were  9  active  cases  and  12  other  cases  for 
each  death — ratios  much  larger  than  those  which  have  been  used  in 
calculating  the  number  of  "living  cases"  from  the  number  of  reported 
deaths. 

If  the  ratios  found  to  obtain  in  Framingham  may  be  applied  in 
this  State,  last  year  there  were  more  than  175,000  cases  of  tuberculosis 
in  Illinois,  and  of  these  more  than  75,000  were  active.  If  they  are 
applied  to  Chicago,  the  Health  Commissioner's  estimate  of  60,482  cases 
for  1916  appears  to  be  conservative.^^  Again,  if  applied  to  the  State 
outside  of  Chicago,  the  estimate  of  50,000  active  cases  recently  made 
by  the  President  of  the  Illinois  Tuberculosis  Association  and  based 
upon  considerable  investigation,  finds  a  degree  of  support.^*  The  truth 
is  that  tuberculosis  is  a  very  prevalent  disease  and  when  looked  for  can 
be  found  in  much  larger  degree  than  is  commonly  realized. 

"  See  Part  II  of  this  report,  Special  Report  V. 

"The  number  of  deaths  from  pulmonary  tuberculosis  was  7,481  ;  from  all  forms 
of  tuberculosis,  8,402 ;  from  pneumonia,  which  ranked  second,  8,277.  The  total 
number  of  deaths  reported  was  89,428  ;  hence  tuberculosis  was  the  cause  of  death 
in  more  than  1  case  in  11. 

"  Estimate  made  in  connection  with  the  findings  of  the  tuberculosis  survey  con- 
ducted by  the  Chicago  Health  Department.  For  the  report  of  th^e  results  of  this 
survey,  see  City  of  Chicago,  Municipal  Tuberculosis  Sanitarium,  Annual  Report, 
1917,  pp.  96-119. 

"  -See  Division  of  Tuberculosis,  the  Department  of  Public  Health,  in  Reports  to 
the  Governor,  1917-1918,  p.  471. 

— 4  H  I 


50 

Not  only  is  tuberculosis  a  very  prevalent  disease ;  it  is  also  a  disease 
appearing  in  active  form  most  frequently  among  those  of  working  years 
in  wage-earning  families,  is  of  relatively  long  duration,  and  with  un- 
usual frequency  reduces  families  to  poverty  and  dependency.  The 
records  of  a  large  number  of  plants  and  of  the  offices  and  selling  forces 
connected  with  them,  show  that  in  the  three  years  1915  to  1917,  89  of 
146  ■emplo3^ees  afflicted  with  tuberculosis  were  disabled  for  more  than 
180  days  per  year.  Many  of  these  were  never  able  to  return  to  work  at 
all.  The  Commission's  investigations  of  families  in  receipt  of  charity 
show  as  the  outstanding  fact  that  cases  of  chronic  illness  are  a  very  im- 
portant cause  of  dependency  and  that  tuberculosis  is  as  important  among 
these  chronic  diseases  as  all  others  combined. ^^  The  "white  plague" 
presents  for  solution  in  Illinois  a  larger  problem  than  that  presented 
by  any  other  disease^  and  though  its  ravages  have  been  fatal  in  relatively 
fewer  cases  as  the  years  have  gone  by,^^  the  return  of  soldiers  from  the 
front  and  the  increased  cost  of  living  will  tend  to  increase  the  dimensions 
of  the  problem  for  a  time.  Already  more  than  1,500  soldiers  have  been 
returned  to  Illinois  afflicted  with  tuberculosis  and  the  experience  of  the 
civil  populations  of  the  European  countries  has  shown  that  increasing 
difficulties  connected  with  the  food  supply  have  been  accompanied  by  an 
increased  death  rate  from  tuberculosis.^" 

It  is  generally  accepted  that  most  tuberculosis  infections  occur  in 
early  childhood.  Dr.  Armstrong  states  that  "A  recent  Von  Pirquet 
tuberculin  studv  of  children  between  the  ages  of  one  and  seven  vears  in 
Framingham  indicated  that  33  per  cent  of  them  had  already  been 
infected,  though  up  to  that  time  the  cases  of  actual  disease  were  few."^^ 
More  than  fifty  per  cent  of  the  cases  found  in  the  Chicago  Tuberculosis 
Survey  were  of  children  under  fourteen  years  of  age.  In  view  of  this 
fact  infant  welfare  work  and  thorough  medical  supervision  of  school 
children  find  an  important  place  in  the  prevention  and  cure  of  tubercu- 
losis. So  does  the  sanitation  of  milk,  for,  to  quote  Dr.  Armstrong 
again,  "It  has  been  recently  pointed  out  by  Cobbett  that  the  percentage 
of  cervical  adenitis  among  children  which  is  definitely  of  bovine  origin 
is  75  per  cent  of  the  cases."  And  so  do  better  housing,  better  living 
conditions  generally,  and  opportunities  for  recreation  under  suitable 
conditions. 

The  more  direct  campaign  against  tuberculosis,  it  is  agreed  by  those 
with  most  experience  in  this  field  of  work,  calls  for  community  surveys 
and  careful  physical  examination  of  people  at  work  so  as  to  locate  cases 
while  in  the  incipient  stage  and  for  the  fullest  reporting  of  cases  by 
attending  physicians;  for  sanatoria  in  which  the  worst  of  the  open  cases 
can  be  isolated  and  treated  indefinitely  and  in  which  a  larger  number 
can  be  treated  temporarily  and  more  carefully  instructed  in  proper 
living  and  exercise  of  care  when  returned  to  their  homes;  dispensaries 
for  diagnosing,  medicating  and  advising  those  who  do  not  have  sani- 

"  See  discussions  in  Chapter  I  above  and  Special  Report  I. 

"The  Census  (Mortality  Statistics,  1916,  p.  42)  reports  the  annual  average  of 
death  rates  from  tuberculosis  as  168.7  per  100,000  population  for  the  years  1906  to 
1910,  as  192.5  for  the  years  1901  to  1905. 

^'  See  paper  by  B.  A.  Armstrong,  M.  D.,  on  "Civilian  Tuberculosis  Control  Fol- 
lowing War  Conditions,"  in  Aiinerican  Journal  of  Public  Health,  December,  1918. 

"  Reference  cited  above. 


51 

tarium  treatment  or  who  have  been  discharged  after  treatment;  and  a 
visiting  nurse  service. 

The  city  of  Chicago  stands  out  prominently  among  American  com- 
munities combating  tuberculosis.  It  provides  a  Municipal  Tuberculosis 
Sanitarium  with  750  beds;  8  dispensaries  scientifically  located,  in  charge 
of  physicians  and  open  every  day  and  part  of  the  evenings ;  a  large  corps 
of  nurses;  and  thirteen  fresh-air  schools  in  which  743  children  were  en- 
rolled, .taught  and  cared  for  in  1916-17.^^  In  this  connection  it  should 
be  said  that  the  Chicago  Tuberculosis  Institute  organized  seven  dis- 
pensaries in  1907  and  1908.  These  were  taken  over  by  the  city  in  1910; 
more  recently  they  have  been  reorganized  and  the  number  added  to. 
The  dispensary  cases  are  effectively  followed  up  and  in  accordance  with 
the  customary  routine,  the  several  members  of  the  family  find  place 
on  the  dispensary  list  when  the  name  of  one  member  is  registered  there. -° 

In  Illinois  outside  of  Chicago  only  an  effective  beginning  has  been 
made  in  dealing  with  the  tuberculosis  problem.  As  already  stated,^^ 
the  Department  of  Public  Health  has  issued  rules  requiring  the  reporting 
of  cases  of  tuberculosis  by  attending  physicians  and  for  the  control  of  the 
tuberculous.  It  has  also  organized  a  Division  of  Tuberculosis.  This  is 
effective  in  securing  the  adoption  of  sanatoria  in  the  several  counties 
or  cities,  in  the  proper  organization  of  these,  in  the  training  of  the 
needed  public  health  nurses,  in  holding  conferences,  etc. 

A  number  of  the  states  have  made  state-wide  provision  for  the  care 
of  the  tuberculous.^^  Pennsylvania,  where  a  few  years  ago  there  were 
three  large  hospitals  and  114  dispensaries  supported  by  the  state,  is 
the  most  conspicuous  example  of  this.  Some  other  states,  e.  g.  Wisconsin, 
combine  a  state  institution  wdth  subsidies  to  and  control  over  local  insti- 
tutions, while  a  few  other  states  have  a  system  of  subsidies  to  local  in- 
stitutions accompanied  by  more  or  less  control  over  them.  In  Illinois, 
however,  there  is  neither  a  system  of  state  institutions  nor  a  S3'stem  of 
subsidies,  and  there  is  only  a  limited  official  control  of  the  local  insti- 
tutions established.  Here  an  effort  is  being  made  to  solve  the  problem 
by  county  and  city  sanatoria,  dispensaries,  and  public  health  nurses. 
This  has  the  advantage  of  bringing  the  institutions  into  closer  touch 
with  the  community,  but  how  effective  the  plan  will  be  remains  to  be  seen. 
Whether  the  institutions  will  be  properly  organized  and  administered 
according  to  the  best  standards  and  properly  supported  and  whether  they 
will  be  made  available  in  those  parts  of  the  State  where  the  burden  of 
taxation  is  most  keenly  felt  and  the  appreciation  of  the  problem  is  least, 
is  a  question  to  be  answered  only  by  experience. 

IJnder  the  "Glackin  Law,"  enacted  in  1915,^^  "the  county  board 
of  each  county  in  this  State  shall  have  the  power  in  the  manner  herein- 
after provided,  to  establish  and  maintain  a  county  tuberculosis  sani- 

"  For  a  fuU  account  of  the"  activities  of  these  several  institutions,  see  City  of 
Chicago  Municipal  Tuberculosis  Sanitarium,  Annual  Report,  1917,  especially  pp. 
1-125. 

^^  In  1918  the  dispensaries  registered  17,953  new  cases;  the  number  of  patients 
treated  was  56,394  ;  the  number  of  visits  to  the  dispensaries  was  77,978. 

"  See  discussion  earlier  in  this  chapter 

"  See  A  Report  on  State  Public  Health  Work,  Based  on  a  Survey  of  State  Boards 
of  Health,  by  Charles  V.  Chapin,  M.  D.,  1916. 

23  Approved  June  28,  and  in  effect  July  1,  1915   (Laws,  1915,  p  346). 


52 

tarium,  and  branches,  dispensaries,  and  other  auxiliary  institutions  con- 
nected with  the  same,  within  the  limits  of  each  county,  for  the  use  and 
benefit  of  the  inhabitants  thereof,  for  the  treatment  and  care  of  persons 
afflicted  with  tuberculosis,  and  shall  have  power  to  levy  a  tax  of  not  to 
exceed  three  mills  on  the  dollar  annually"  to  constitute  a  "Tuberculosis 
Sanitarium  Fund."  When  established,  the  location  and  building  plans 
for  the  sanitarium  are  to  be  approved  by  the  Department  of  Public 
Health;  the  location  and  management  are  to  be  entirely  divorced  from 
the  poor  farm  or  infirmary;  it  is  to  be  under  the  control  of  a  board  of 
three  directors;  this  board  may  extend  the  use  and  treatment  of  the 
sanitarium  to  residents  of  other  counties  of  the  State  upon  such  terms 
as  they  may  establish.  The  decision  as  to  whether  a  sanitarium  shall 
be  established  and  the  levy  of  the  necessary  tax  for  its  support  authorized 
is  determined  by  referendum  vote. 

The  enactment  of  the  Glackin  Law  had  been  preceded  by  the  enact- 
ment of  a  similar  law  conferring  like  powers  but  with  a  maximum  tax 
levy  of  one  mill,  upon  cities  and  villages.^^  Under  the  municipal  sani- 
tarium act,  Danville,  Elgin,  Springfield,  Rock  Island,  Rockford,  and 
Peoria,  have  established  sanatoria.  Under  the  Glackin  Law,  seven 
counties  in  1916  voted  to  establish  sanatoria;  thirty-three  others  voted 
affirmatively  on  referenda  submitted  at  the  last  general  election.^^  As 
yet,  however,  few  of  these  have  been  built.  At  the  present  time  the 
number  of  sanitarium  beds  outside  of  Chicago,  it  has  been  recently 
stated,  does  not  exceed  250  and  most  of  these  are  in  private  sanatoria 
operated  at  relatively  high  rates. ^^  In  some  instances  the  provision  of 
dispensary  and  nursing  service  has  preceded  the  building  and  opening 
of  sanatoria,  and  in  a  year  or  so  the  number  of  free  beds  available  for 
patients,  and  without  regard  to  pecuniary  conditions  will  be  very 
materially  increased. 

In  addition  to  this  public  provision,  there  is  the  provision  made  by 
employers  and  others  which  supplements  that  made  by  the  cities  and 
counties.  The  educational  activity  of  the  Illinois  Tuberculosis  Asso- 
ciation, the  Chicago  Tuberculosis  Institute  and  other  organizations  is 
an  important  factor  in  the  advance  being  made. 

One  problem  which  has  not  been  arid  is  not  being  solved  to  any 
extent  except  by  charity  is  the  financial  one  of  supporting  the  depen- 
dents of  the  tuberculous  wage-earner  whose  recovery  requires  that  he 
should  stop  work  while  under  treatment  in  the  sanitarium  or  at  home. 
It  would  appear  that  many  of  the  tuberculous  cannot  be  successfully 
treated  if  they  continue  in  their  regular  employment.  Again,  the 
tuberculous  are  having  increasing  difficulty  in  keeping  their  employment 
because  of  medical  examinations  and  rejections  for  fear  of  danger  to 
others.     Further,  successful  treatment  when  it  requires  rest,  is  a  rela- 

2*  Act  approved  March  7,  in  force  July  1,  1908.  Amended  by  act  approved  June 
27,  in  force  July  1,  1913. 

28  The  seven  counties  voting-  in  1916  to  establish  sanatoria  were : Adams,  Cham- 
paign, Morgan,  McLean,  Ogle,  Livingston,  and  LaSalle.  The  33  voting  favorably 
(all  in  which  a  referendum  was  submitted  were:  Bone,  Bureau,  Ch>ristian.  Clark, 
Clay,  DeWitt,  Coles,  Crawford,  DeKalb,  Douglas,  Fulton,  Grundy,  Henry,  Jackson, 
Jefferson,  Kane,  Lee,  Logan,  McDonough,  Macon,  Madison,  Marion,  Piatt,  Pike, 
Randolph,  Scott,  Stephenson,  Tazewell,  Vermillion,  Whitesides,  Will,  Winnebago, 
and  Woodford. 

"See  report,  Division  of  Tuberculosis,  cited  above,  p.   471. 


53 

tively  long  process.  Finally,  in  many  benefit  funds  no  benefits  are 
allowed  in  case  of  tuberculosis  or  other  chronic  diseases  or  those  allowed 
are  for  a  relatively  short  time.  The  insurance  companies,  as  a  rule, 
limit  benefits  in  the  case  of  tuberculosis  to  a  much  shorter  period  than 
for  most  diseases  covered  by  health  policies.  The  result  generally  is 
that  men  keep  their  jobs  as  long  as  they  can  in  order  to  support  their 
families.  Inevitably  the  time  comes  when  they  can  no  longer  work 
and  there  is  little  chance  of  successful  treatment.  Two  tuberculosis 
specialists  with  wide  experience  have  testified  before  the  Commission  that 
in  not  more  than  two  or  three  per  cent  of  the  dispensary  cases  where  they 
have  advised  rest  or  work  for  a  limited  number  of  hours,  has  the  advice 
been  followed.  The  reason  for  this,  it  was  stated,  is  not  found  in  any 
false  hope  of  an  early  recovery  while  at  work,  but  in  the  economic 
necessity  of  supporting  dependents.  Much  other  testimony  to  the  same 
effect  was  presented  to  the  Commission  at  its  public  hearings  and  con- 
ferences. Obviously  one  gap  in  the  provision  for  the  tuberculous  will 
not  be  closed  under  the  plans  being  developed.  Those  who  have  given 
the  Commission  the  benefit  of  their  thought  and  experience  have  agreed 
that  a  financial  benefit  to  cover  the  actual  needs  of  dependents  is 
necessary  if  many  wage-earners  with  dependents  are  to  have  successful 
treatment  in  the  institutions  being  provided  at  public  expense  and  open 
to  all  residents  as  a  matter  of  right.  Some  have  suggested  that  pro- 
vision should  be  made  for  a  cash  benefit  not  unlike  that  granted  (under 
the  "funds  to  parents  act")  to  mothers  with  permanently  disabled 
husbands.  Others  have  suggested  that  in  so  far  as  wage-earners  are 
concerned,  the  situation  might  be  met  by  insurance  with  benefits  not 
limited  to  a  certain  number  of  weeks  or  months  in  the  year. 

Of  course  the  majority  of  the  tuberculous  can  do  a  certain  amount 
of  work  while  being  properly  treated,  and  in  this  way  earn  at  least  a  part 
of  the  cost  of  supporting  themselves  and  their  families — provided  the 
work  is  of  a  suitable  kind.  Unfortunately  suitable  employment  is 
frequently  hard  to  find,  and  experience  shows  that  a  very  large  per- 
centage of  those  discharged  from  the  sanatoria  soon  break  down  in  spite 
of  the  knowledge  they  have  gained  with  reference  to  diet  and  care,  when 
they  must  fit  into  industrial  life  in  the  usual  way.  The  experience  of 
the  Committee  for  the  care  of  the  Jewish  Tuberculous,  New  York  City, 
is  of  importance  in  connection  with  this  and  other  phases  of  the 
problem.^^ 

The  Committee  referred  to  found  after  two  years  of  experience 
"that  of  the  patients  discharged  from  one  sanitarium,  the  cases  being 
classed  as  improved,  quiescent,  or  arrested,  about  45  per  cent  were 
worse  or  dead  within  six  months  to  two  years  after  discharge."  In 
order  to  meet  this  situation  a  well-worked  out  system  of  family  care 
and  a  factory  to  give  employment  to  patients  with  negative  sputum 
have  been  established.     To  quote  from  the  Executive  Secretary: 

"Our  method  of  treatment  includes  a  physical  examination,  and 
periodic  reexaminations "  of  all  members  of  the  family,  with  particular 

"  See  published  annual  reports,  and  article  by  the  Executive  Secretary,  Edward 
Hochhauser  on  "Home  Treatment  for  the  Tuberculous,"  in  Modern  Hospital,  March, 
1917. 


54 

emphasis  on  the  patient.  Medical  aid  is  given  in  the  form  of  extra 
diet,  medicines,  or  if  the  mother  is  the  patient,  relief  from  heavy  house- 
work. When  financial  assistance  is  necessary  for  rent,  food,  or  cloth- 
ing, it  is  granted  through  the  committee,  the  United  Hebrew  Charities, 
a  part  of  our  committee,  cooperating  in  each  case.  The  care  given 
ranges  from  medical  care,  home  visitation  by  our  nurses,  dental  treat- 
ment, to  an  annual  allowance  of  $600  for  food,  rent,  and  clothing,  for 
one  family  with  seven  children  under  15  years  of  age. 

"Our  purpose  is  not  only  to  arrest  the  disease,  but  also  to  return 
the  patient  to  economic  usefulness  and  independence.  The  patient  on 
his  discharge  is  often  able  to  work  but  part  time.  He  needs  to  be  carried 
through  a  period  of  industrial  convalescence,  and  gradually  returned 
to  old-time  working  capacity. 

"Eeturning  a  patient  to  industrial  life  is  distinctly  a  part  of  his 
treatment.  At  least  a  contributing  cause  in  the  relapses  that  occur 
is  the  fact  that  the  transition  from  no  activity,  or  a  few  hours  of  institu- 
tional work  to  the  demands  of  industry;  a  full  day's  work  at  full  speed 
is  too  great.  We  found,  however,  that  employers  were  not  disposed  to 
allow  part-time  work — they  could  not  afford  to  keep  part-time  workers. 
To  safeguard  the  health  of  the  workers,  control  the  hours  and  amount 
of  work,  and  the  working  conditions,  we  found  it  necessary  to  start  a 
factory  of  our  own." 

The  work  provided  by  the  Committee  is  in  the  needle  trades,  in 
which  some  sixty  per  cent  of  the  patients  had  experience.  Those  who 
can  be  suitably  provided  for  otherwise,  go  into  other  employments; 
those  who  cannot  be  and  are  able  to  work  without  danger  to  them- 
selves and  risk  to  others  are  given  employment  here  under  suitable  con- 
ditions and  careful  supervision.  The  experiment  combining  home  care 
and  industrial  employment  of  those  able  to  work  part  or  full  time,  has 
been  successful  in  reducing  the  relapses  among  those  discharged  from 
sanitarium  treatment  from  45  to  less  than  15  per  cent.  By  the  experi- 
ment, "we  have  demonstrated,"  says  the  Executive  Secretary,  "that  by 
after-care  or  home  care  we  can  save  many  patients '  from  relapses  and 
premature  death.  This  treatment,  however^  must  be  intensive,  and  where 
relief  is  necessary  it  must  be  generous.  This  form  of  medical  social 
treatment,  by  treating  patients  and  their  families  in  their  own  homes, 
can  be  readily  extended,  as  the  cost  is  not  prohibitive,  and  can  be  main- 
tained by  the  patients  when  they  are  restored  to  industrial  usefulness." 

Thus,  this  experience  in  New  York  confirms  the  opinions  of  those 
who  testified  before  the  Commission  that  there  is  need  for  financial 
support  and  suitable  employment  as  well  as  for  sanatoria,  dispensaries 
and  nursing  service. 

(5)   The  Campaign  Against  Venereal  Disease. 

Society  is  coming  more  and  more  to  recognize  the  significance  of 
the  menace  of  the  venereal  diseases.  Somewhat  more  slowly  is  coming 
a  community  sense  of  responsibility  for  their  control  through  education, 
prevention  and  treatment.  The  War  which  revealed  how  venereal 
disease  rendered  many  of  our  young  men  unfit  for  military  service  and 
showed  that  military  leaders  recognize  in  it  a  greater  danger  than  in  the 


55 

bullets  of  the  enemy,  has  had  much  to  do  with  the  arousing  of  public 
interest  in  the  problem. 

Patients  suffering  from  venereal  diseases  seek  treatment  from 
several  different  sources.  Many  become  private  patients  of  practicing 
physicians.  Many  others,  especially  in  cities,  seek  treatment  in  dis- 
pensaries and  clinics.  Ingenious  advertising  and  a  desire  for  secrecy 
lead  many  others  to  resort  to  quacks  who  thrive  on  their  patients' 
ignorance  and  fears.  Many  others  do  not  consult  doctors  at  all  but 
purchase  remedies  from  drug  stores  and  administer  their  own  treatment. 

There  are  no  adequate  statistics^^  available  concerning  the  number 
of  venereal  disease  patients  under  treatment  by  private  physicians  in 
Illinois  nor  concerning  the  efficacy  of  the  treatment  they  receive.  There 
is  frequent  testimony  from  physicians  to  the  effect  that  many  such 
patients  discontinue  treatment  as  soon  as  the  distressing  symptoms 
disappear  but  long  before  cure  has  been  effected. 

The  Eed  League,  a  Chicago  organization,  "devoted  to  the  study, 
prevention  and  treatment  of  venereal  diseases,''  made  a  survey  in  1917 
of  the  hospitals  and  dispensaries  in  Chicago,  with  reference  to  their 
facilities  for  the  diagnosis  and  treatment  of  venereal  diseases.  It  found 
that  eleven  out  of  forty-one  hospitals  visited  admit  patients  suffering 
from  these  in  their  active  infectious  stages,  but  that  only  one  hospital 
admitted  such  patients  who  were  unable  to  pay  for  their  care.  A  larger 
number  admit  patients  who  have  these  diseases  in  non-infectious  forms. 
Of  nineteen  dispensaries  visited,  it  found  but  three  adequately  equipped 
to  treat  such  patients.  The  general  conclusions  of  its  survey  are  here 
given : 

"1.  At  many  of  the  dispensaries  individual  care  and  treatment  of  the 
highest  order  was  given  the  patients.  Of  the  total  number  of  dispensaries 
visited  there  were  three  only  whose  records  demonstrated  their  efficiency 
according  to  the  standards  indicated  by  our  questionnaire.  Two  of 
these  treat  large  numbers  of  patients  and  one  a  very  small  number. 

"2.  With  these  exceptions  the  dispensaries  showed  their  inefficiency 
either  in  lack  of  adequate  equipment,  or  incomplete  history  cards  which 
failed  to  record  a  proper  history,  the  date  of  visits,  the  treatment  given 
and  results  of  treatment,  or  in  failure  to  have  any  follow-up  system  such 
as  date  cards  and  social  service  worker. 

"3.  The  explanation  of  this  inefficiency  was  given  as  insufficient 
funds  to  furnish  clerical  force,  lack  of  interest  on  the  part  of  the  attend- 
ing physicians  and  no  regulation  on  the  part  of  law  or  health  department 
to  enforce  the  proper  recognition  and  treatment  of  venereal  disease." 

It  must  be  borne  in  mind  that  this  survey  was  made  prior  to  the  time 
when  venereal  diseases  were  made  reportable  throughout  the  State  and 
before  the  War  had  brought  to  the  attention  of  the  public,  as  it  since  has 
done  so  forcibly,  the  significance  of  the  venereal  disease  peril.  Though 
the  Red  League  found  most  of  the  dispensaries  giving  inadequate  service 
to  this  group  of  patients,  that  organization  recognized  the  dispensary  as 
an  effective  and  economical  means  of  providing  adequate  treatment  for 

"  Venereal  diseases  are  to  be  reported  by  doctors  and  druggists  but  this  order 
became  effective  only  recently.  The  reporting  has  as  yet  been  only  partial.  Th(e 
truth  is  that  only  a  small  part  of  the  cases  have  been  reported. 


56 

venereal  disease  and  on  the  basis  of  this  conclusion,  opened  a  special 
venereal  disease  dispensary  under  its  own  management. 

There  is  no  way  of  measuring  the  patronage  of  the  quack  venereal 
disease  specialists.  It  is  large,  beyond  doubt.  Publicity,  the  establish- 
ment of  better  and  more  widely  known  dispensary  facilities  and  a  more 
rigid  enforcement  of  medical  practice  laws,  are  unquestionably  tending 
to  divert  some  of  the  patients  who  would  otherwise  become  the  victims 
of  these  charlatans.  Some  of  the  better  newspapers  no  longer  accept 
their  advertisements  but  they  are  still  able  to  reach  a  large  number  of 
readers,  especially  through  the  foreign  language  press  and  through  papers 
having  wide  circulation  in  the  smaller  cities  and  towns.  Their  booklets 
of  lies  and  distorted  truths  still  find  thousands  of  readers  and  their 
advertisements  of  fake  cures  are  displayed  in  public  toilet  rooms  almost 
universally. 

While  most  patients  suffering  from  venereal  diseases  are  not  con- 
fined to  their  beds  and  can  be  effectively  treated  as  ambulatory  patients, 
there  is  a  small  percentage  who  need  hospital  care.  For  these,  facilities 
are  very  inadequate.  Many  hospitals  will  admit  no  patients  of  this  class, 
either  l3ecause  they  have  no  facilities  for  their  segregation  or  because  the 
management  of  the  hospital  feels  that  syphilitics  and  gonorrhoeics  do  not 
deserve  the  consideration  and  care  readily  granted  to  patients  suffering 
from  other  less  odious  ailments.  Eecently  the  Department  of  Health  of 
Chicago  has  established  a  hospital  for  the  treatment  of  women  offenders 
suffering  from  venereal  disease. 

In  June  1917,  the  City  Council  of  Chicago  passed  an  ordinance  re- 
quiring the  reporting  of  venereal  diseases.  More  recently  the  State  De- 
partment of  Public  Health  has  made  mandatory  the  reporting  of  these 
diseases  throughout  the  State.  The  provisions  of  these  two  regulations 
are  very  similiar.  In  general  they  provide  that  every  physician,  manager 
of  a  medical  institution  and  every  other  person  giving  treatment  for 
syphilis,  gonorrhoea  and  chancroid  shall  report  each  such  case  to  the 
designated  health  authorities  within  a  fixed  brief  period  after  the  case 
has  been  diagnosed.  This  report  sHall  contain  the  age,  sex,  color, 
marital  condition,  occupation  (in  State  regulations  the  name  of  the 
employer),  the  nature  and  previous  duration  of  the  disease  and  its 
probable  origin.  Instead  of  the  name  and  address  of  the  patient,  the 
physician  or  person  reporting  may  use  a  key  number  by  which  he  may 
if  required  at  any  time  identify  the  patient.  Should  the  patient  dis- 
continue treatment  before  being  discharged  by  the  physician  treating 
him  and  should  that  physician  within  a  period  of  ten  days  not  receive 
notification  from  some  other  physician  that  the  patient  in  question  is 
now  under  his  treatment,  it  becomes  the  duty  of  the  first  physician  to 
report  to  the  proper  health  authorities  the  name  and  address  of  the 
patient,  the  name  of  the  disease  for  which  he  has  been  under  treatment 
and  the  fact  that  he  has  discontinued  treatment.  The  health  authorities 
may  then  proceed  as  in  the  case  of  any  other  contagious  disease. 

Probably  the  greatest  good  to  come  from  these  regulations  is  that 
of  keeping  undeu  treatment  those  pelrsons  sufflering  from  venereal 
diseases  who  seek  treatment  from  physicians,  at  least  until  their  disease 


57 

is  no  longer  infectious.  Of  course  this  is  one  of  the  most  effective  means 
of  preventing  the  spread  of  these  diseases. 

The  Congress  of  the  United  States  has  appropriated  the  sum  of 
$2,000,000  to  be  used  during  the  two  year  period,  July  1918  to  July 
1920,  in  venereal  disease  control.  The  one  million  set  apart  to  be  used 
during  the  first  year  is  divided  among  the  several  states  on  the  basis  of 
population.  Illinois'  portion  for  this  first  year  is  something  over 
$60,000.  This  money  is  to  be  used  for  education  in  social  hygiene  and 
in  the  prevention  and  treatment  of  venereal  diseases.  This  program 
is  being  carried  out  by  the  State  Department  of  Public  Health  in  co- 
operation with  the  United  States  Public  Health  Service.  One  half  of 
the  sum  available  is  to  be  used  for  treatment.  The  State  Department 
of  Public  Health  has  wisely  decided  to  use  this  money  for  the  purchase 
of  Arsephenamine  (Salvarsan)  to  be  used  in  the  treatment  of  persons 
suffering  from  syphilis  in  an  infectious  stage  and  who  are  unable  to  pay 
for  such  treatment.  In  Chicago  much  of  this  treatment  will  be  given 
in  dispensaries.  The  amount  of  money  available  for  Illinois  the  second 
year  under  the  Act  of  Congress  will  be  dependent  within  limits  upon  an 
appropriation  of  a  like  sum  by  the  State  Legislature.  In  other  words 
an  appropriation  of  $60,000  or  less  by  the  present  General  Assembly 
for  venereal  disease  control  in  Illinois  in  1919-20  will  be  augmented  by 
a  like  sum  from  the  National  Grovernment.  What  'further  action 
Congress  will  take  in  the  matter  will  no  doubt  be  dependent  largely 
upon  the  success  of  this  initial  experiment. 

Making  venereal  diseases  reportable  and  the  appropriation  of  public 
money  for  their  control  and  prevention  are  two  steps  of  primary  im- 
portance in  thel  camp^aign  against  these  diseases.  They  mark  the 
recognition  of  venereal  disease  as  a  community  problem  and  the  begin- 
ning of  community  action  for  their  control  and  possibly  eventual 
eradication. 

(6)  Maternity  Care. 

The  child-bearing  function  brings  a  sickness  problem  both  to  the 
mother  and  to  the  offspring.  It  has  been  stated  that  childbirth  causes 
more  deaths  among  women  between  the  ages  of  fifteen  and  forty-four 
than  any  disease  except  tuberculosis.^^  The  total  deaths  from  child- 
birth in  Chicago  during  1917  was  335,  which  was  between  5  and  6 
deaths  per  1,000  births. ^^  The  mortality  rate  for  infants  under  1  year 
of  age  is  also  very  high.  It  is  generally  believed  that  both  of  these 
rates  can  be  greatly  reduced  if    adequate  and  proper  care  are  furnished. 

In  recent  years  considerable  attention  has  been  given  in  this  anrf 
other  countries  to  methods  of  reducing  death  incidental  to  bearing 
children  and  among  infants.  In  the  case  of  the  mother  two  proposals 
have  been  made — namely,  provision  for  maternity  benefit,  and  the  in- 
creased and  improved  facilities  for  advice  and  medical  care  during  the 

29  Julia  Lathrop,  Chief  U.  S.  Children's  Bureau,  at  Conference  on  Social  Work, 
May  16,  1918,  in  paper  on  State  Care  for  Mothers  and  Infants. 

*"  In  1916,  there  were  47,769  births  reported  to  the  Health  Department.  The 
Department  estimated  this  to  be  about  75  per  cent  of  the  total  births,  whichi  would 
amount  on  this  basis  to  63,692.  The  335  deaths  of  mothers  in  childbirth  would  then 
give  a  rate  of  between  5  and  6  per  1,000. 


58 

period  of  pregnancy  and  at  the  time  of  confinement.  To  relieve  the 
economic  pressure  that  is  entailed  by  sickness  and  loss  of  employment, 
a  cash  maternity  benefit  has  been  proposed,  a  method  employed  by  the 
states  in  Australia.  From  October  10,  1912,  to  June  30,  1916,  the 
government  in  Australia  granted  £2,441,355  in  maternity  benefits  to 
488,271  cases.  It  is  stated  that  claims  were  allowed  in  93  per  cent  of 
the  total  number  of  confinements  in  the  Commonwealth.  The  payment 
of  cash  benefits,  however,  does  not  seem  to  solve  the  problem  in  these 
countries.  In  August,  1917,  a  parliamentary  committee  on  Maternal 
Mortality  in  Childbirth  stated: 

"Your  Committee  is  of  the  opinion  that  much  greater  benefit  could 
be  obtained  from  the  large  sum  of  money  spent  annually  than  is  being 
obtained  under  the  present  system." 

"In  the  opinion  of  your  Committee,  however,  there  is  imperative 
need  for  immediate  extension  of  existing  facilities  for  pregnant  women 
to  obtain  skilled  advice  concerning  their  health  before  their  confinement, 
and  the  Commonwealth  Government  might  well  provide  financial  assist- 
ance to  enable  women^s  hospitals  and  similar  institutions  to  inaugurate 
or  extend  such  branches  of  their  activity,  and  might  even  undertake  the 
provision  of  facilities  in  places  where  they  are  as  yet  non-existent. 
The  return  to  the  community  would  almost  certainly  more  than  compen- 
sate for  the  expenditure  involved."^^ 

A  similar  opinion  was  expressed  by  the  Local  Government  Board 
of  England  and  Wales  in  its  report  of  1917  in  which  the  necessity  for 
increasing  the  protection  of  mothers  and  babies  was  emphasized.  They 
reported  a  program  already  in  operation  which  included  centers  for 
hygienic  and  medical  advice  for  mothers  and  babies,  provision  for  care 
at  childbirth,  arrangements  for  hospital  care  where  needed,  and  home 
visiting  by  health  visitors.^^ 

It  would  seem,  therefore,  that  in  other  countries  there  is  a  growing 
opinion  in  favor  of  increasing  the  facilities  for  medical  care  before  and 
during  confinement  as  a  part  of  a  state  or  national  policy. 

The  Commission  is  unable  to  find  that  maternity  care  has  as  yet 
received  a  large  amount  of  organized  or  community  attention  in  this 
State.  In  the  "Block  Studies"  made  in  Chicago  695  maternity  cases 
were  found.  Complete  information  was  received  concerning  the  costs 
in  680  of  the  cases.  In  83,  or  11.9  per  cent  of  these,  the  entire  medical 
and  nursing  service  was  free.  In  129,  or  18.6  per  cent  of  the  cases,  a 
part  of  the  service  was  free.  In  other  words  in  30.5  per  cent  of  the 
cases  all  or  part  of  the  care  was  furnished  to  the  patient  without  expense. 

An  examination  of  the  nature  of  this  free  service  shows  that  in  44 
cases  out  of  378  employing  a  physician,  the  doctors'  services  were  unpaid; 
in  7  of  the  277  mid-wife  cases,  and  in  44  of  the  95  hospital  cases  the 
service  was  furnished  without  charge  to  the  patient.  A  similar  situation 
is  found  in  the  nursing  care,  as  this  service  was  also  furnished  free  in  79 
out  of  the  217  cases  in  which  special  nursing  service  was  received. 
Thus  it  is  evident  that  in  a  considerable  number  of  cases  when  the 


'1  Miss  Lathrop,  op.  cit. 
«2  Ibid. 


59 

patient  is  unable  to  pay  the  necessary  and  frequently  meager  service 
is  furnished  free  by  attendants  who  are  ordinarily  paid  for  such  care, 
and  in  other  cases  by  social  agencies  that  are  so  organized  that  they 
furnish  the  care  free  to  those  who  are  unable  to  get  it  in  any  other 
way.  The  percentage  of  those  receiving  free  service  varies  widely  among 
the  different  nationalities,  as  may  be  seen  from  the  following  table. 

REMUNERATED    AND    FREE    SERVICE    IN   MATERNITY    CASES    BY 

NATIONALITY. 


Nationality. 

Total 

number 

cases. 

Number 
with 
paid 

service 
only. 

Number 
with  free 
service. 

Number 

with 

both  paid 

and  free 

service. 

Number  and  per 

cent  of  those 

receiving  some  free 

service. 

Number. 

Per  cent. 

Total 

695 

477 

83 

129 

212 

30.5 

United  States  white 

162 
39 
26 
39 
26 
67 
42 
27 

174 
23 
70 

99 
13 
21 
23 
16 
45 
19 
27 
143 
19 
52 

7 

11 

2 

3 

3 

15 

14 

55 
14 
3 
13 
7 
7 
9 

62 
25 
5 
16 
10 
22 
23 

38.2 

United  States  black 

64.1 

Bohemian 

19.2 

German 

41.0 

Irish 

38.4 

ItaUan 

32.8 

Jewish 

54.7 

Lithuanian 

Polish 

21 

7 
4 
8 

28 

4 

16 

16.0 

Scand  navian 

17.4 

Other 

8 

22.8 

Over  against  the  cases  with  free  service  may  be  set  the  pay  cases. 
There  were  597  of  these  concerning  which  the  completed  expenditures 
were  obtained.  The  total  costs  in  these  597  cases  were  $14,311,  or  an 
average  of  $24  per  case.  These  costs  included  all  bills  for  service 
whether  of  physicians,  mid-wife,  nurse  or  hospital.  In  the  328  pay 
cases  employing  a  physician  the  average  charge  was  $23.64.^^  However, 
in  56.4  per  cent  of  these  cases  the  charge  amounted  to  $25  or  more. 
In  the  264  pay  cases  employing  a  mid-wife  the  average  was  $11.42,  but 
in  21.6  per  cent  of  these  cases  the  charge  was  $15  or  over.^*  The  cost 
in  the  48  pay  cases  attended  at  the  hospital  was  $2,093^  or  an  average 
charge  of  $43.60  per  case.^^  The  cost  of  the  nursing  care  varied  with 
the  type  of  nursing.  The  average  for  the  private  nurse  was  $18.23  and 
for  the  visiting  nurse  $2.71,^^  which  means  that  the  bedside  nursing 
averaged  about  a  week. 

The  kind  of  attendance  at  confinements  is  of  interest.  Information 
on  this  point  was  received  in  691  of  the  695  cases.  In  2  of  these  births 
occurred  without  attendants,  leaving  689  cases  with  attendants.  Ninety- 
five  of  these  confinements  were  in  the  hospital  and  594  were  at  home.   In 

••There  were  378  cases  employing  a  physician;  in  44  cases  the  services  were 
free,  in  328  the  services  were  paid  for;  in  6  the  information  was  incomplete. 

'*  There  were  277  mid- wife  cases;  7  were  free,  264  were  pay  cases.  The  infor- 
mation was  incomplete  in  the  remaining  6  cases. 

•'In  48  of  the  95  hospital  cases  the  services  were  paid  for;  in  44  the  services 
were  free  and  in  3  cases  the  information  was  incomplete. 

■*  The  private  nurse  was  employed  in  70  cases  and  full  returns  of  charges  were 
received  in  69  of  these.  A  visiting  nurse  was  employed  in  130,  and  charges  were 
made  in  69  cases.  The  free  cases  included  1  private  nurse,  60  visiting  nurses  and 
17  cases  with  nursing  of  some  other  kind. 


60 

317,  or  53.3  per  cent,  of  the  home  cases  a  physician  was  in  attendance. 
In  247  home  cases,  or  41.5  per  cent,  a  mid-wife,  and  in  30,  or  5.17  per 
cent,  both  a  physician  and  mid-wife  were  in  attendance.  The  mid-wife 
was  more  frequently  employed  by  the  Bohemians,  Italians,  Lithuanians 
and  Poles  than  by  the  other  nationalities.  The  relative  number  of  cases 
employing  a  physician  only,  and  those  employing  a  mid-wife  only  may 
be  seen  in  the  following  table : 

USE   OF  PHYSICIAN  AND   OF   MID-WIFE  IN  HOME   CONFINEMENT   CASES. 


Nationality. 


Total 
number 
of  cases. 


Physician  only. 


Number. 


Per  cent. 


Midwife  only. 


Number. 


Per  cent. 


Physician  and 
midwife. 


Number. 


Per  cent. 


Total 

United  States  white* 
United  States  black. 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian 

Other 


594 

317 

53.3 

247 

41.5 

30 

140 
27 
24 
31 
22 
64 
22 
27 

159 
16 
62 

117 
19 

6 
26 
22 
26 
21 

6 
37 
12 
25 

83.5 
70.3 
25. 
83.8 
100. 
40.6 
95.4 
22.2 
23.2 
75. 
40.3 

22 
5 

17 
3 

15.8 
18.5 
70.8 

9.7 

.0 

56.2 

4.5 
59.2 
69.1 
25. 
53.2 

1 
3 
1 
2 

36 

1 

16 

110 

4 

33 

2 

5 
12 

4 

5.1 


.8 

11.1 

4.1 

6.4 

.0 

3  1 

0 

5 

6 

0 

4 


18. 
7, 


*  Includes  families  where  the  father  was  native  born  of  foreign  born  parents. 

The  niid-wife  only  was  employed  in  70.8  per  cent  of  the  Bohemian, 
69.1  per  cent  of  the  Polish,  59.2  per  cent  of  the  Lithuanian,  and  56.2 
per  cent  of  the  Italian  confinements. 

Public  health  officers  and  physicians  generally  agree  that  licensing 
and  control  over  mid-wives  is  inadequate.  The  importance  of  such  con- 
trol as  a  vital  part  of  the  public  health  administration  may  be  seen  from 
the  following  table  which  consists  of  a  detailed  statement  of  the  edu- 
cation, special  training,  fees  charged,  visits  per  case,  etc.,  of  50  practic- 
ing mid-wives  selected  at  random  from  the  Chicago  Health  Department 
records." 


"  The  Commission  is  under  obligation  to  Miss  Florence  Mason  for  the  privilege 
of  using  the  results  of  her  uncompleted  investigation  of  mid-wives  in  CMcago. 


61 


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63 

It  is  a  matter  of  great  importance,  if  mid-wives  are  permitted  to 
care  for  maternity  cases,  that  their  training  be  of  such  a  character  as 
to  fit  them  for  the  work.  The  majority  of  those  studied  have  been  trained 
in  the  United  States  (37,  of  whom  35  were  trained  in  Chicago). ^^  Only 
4  claimed  to  have  had  a  high  school  course  and  23  stated  that  they  had 
less  general  education  than  the  eight  grades  provided  by  our  public 
school  system.  As  to  the  length  of  special  training  received,  it  will  be 
seen  that  29  took  a  course  of  less  than  1  year,  10  of  1  year  but  less  than 
2,  4  of  2  years  but  less  than  3,  and  2  of  3  years.  One  received  a  license 
by  examination;  1  got  her  training  by  going  with  doctors  to  maternity 
cases.  Three  did  not  report  the  length  of  their  course.  As  to  the 
character  of  training,  so  far  as  this  may  be  judged  from  the  number  who 
had  observed  cases,  and  who  had  had  supervised  practice  cases,  the 
following  interesting  facts  may  be  seen.  Thirty  of  the  50  mid-wives 
had  observed  maternity  cases  before  beginning  their  practice;  7  had  not 
observed  cases;  13  gave  no  information  on  this  point.  Twenty-eight 
claimed  to  have  had  practice  cases  under  supervision;  10  reported  no 
supervised,  practice  cases;  12  gave  no  information  on  this  point.  All 
of  the  10  cases  having  no  supervised  cases,  and  all  of  the  7  not  even 
having  observed  cases  during  their  training,  were  trained  in  Chicago. 
Only  4  claimed  to  have  had  hospital  training  and  three  of  these  received 
their  training  before  coming  to  this  country.  The  above  cases  represent 
about  8.7  per  cent  of  the  knoAvn  practicing  mid-wives  in  Chicago  and 
considering  the  method  of  selection  of  the  group  studied,  there  is  every 
reason  to  believe  that  these  are  typical  cases.  It  is,  therefore,  too 
much  to  expect  that  either  mother  or  babe  will  receive  adequate  care  when 
attended  by  mid- wives  with  no  more  special  training  than  the  majority 
of  those  disclosed  by  this  study.  In  the  face  of  these  facts  there  is 
every  reason  for  strengthening  the  control  over  practicing  mid-wives. 

While  it  is  probably  true  that  inadequate  care  is  more  common  in 
Chicago  than  in  other  parts  of  the  State,  the  evidence  points  clearly  to 
the  fact  that  there  are  other  parts  of  the  State  where  the  care  at  con- 
finement is  insufficient.  During  the  six  months  from  July  1  to  Decem- 
ber 31,  1917  there  were  31,393  births  reported  to  the  Bureau  of  Vital 
Statistics  of  the  State  Department  of  Public  Health. ^^  In  91.7  per  cent 
of  these  cases  a  physician  was  in  attendance;  in  4.5  per  cent  a  mid- 
wife; but  in  1,111  cases  or  3.5  per  cent  there  was  no  "properly  quali- 
fied" attendant.*^  The  conditions  in  certain  of  the  counties,  as  mav 
be  seen  from  the  following  table,  are  not  as  satisfactory  as  the  average 
for  the  State. 


^  One  was  trained  in  Poland,  5  in  Austria,  3  in  Italy,  1  got  license  by  examina- 
tion, 1  "just  went  with  doctors,"  and  2  no  report. 

8^  These  figures  do  not  include  those  for  the  City  of  Chicago  but  do  include  those 
for  Cook  County  outside  of  the  city.  It  should  also  be  noted  that  less  than  two- 
thirds  of  births  are  reported. 

40  "Properly  qualified"  is  employed  by  the  Children's  Bureau  to  mean  that  doctor 
or  mid-wife  was  in  attendance. 


64 

BIRTHS  FOR  SIX  MONTHS  (JULY  1  TO  DECEMBER  31,  1917)  FOR  SELECTED 

COUNTIES  BY  ATTENDANTS. 


County. 


Total 
births. 


Attended 
by  phy- 
sician. 


Percent. 


Attended 

.fey., 

midwife. 


Per  cent. 


Number 

without 

physician 

or  midwife 

attendant. 


Percent. 


Adams 

Alexander. . 

Bureau 

Calhoun 

Cook* 

Fulton 

Henry 

Jackson 

Kane 

Kankakee.. 

Lake 

LaSalle 

Macoupin.. 

Madison 

Monroe 

Putnam 

St.  Clair.... 
Stephenson. 
Washington 
Will 


410 

384 

93.6 

25 

6.0 

0 

191 

170 

89,0 

21 

11.0 

0 

441 

327 

74.1 

79 

17.9 

35 

56 

52 

92.8 

4 

7.1 

0 

2,923 

2,111 

72.2 

378 

12.9 

432 

414 

392 

94.6 

20 

4.8 

2 

386 

362 

93.7 

24 

6.6 

0 

263 

231 

87.2 

31 

11.7 

1 

820 

736 

89.7 

82 

10.0 

2 

307 

293 

95.4 

.   12 

3.9 

0 

537 

431 

80.2 

13 

2.4 

90 

887 

636 

71.7 

220 

24.8 

20 

498 

442 

89.1 

19 

3.8 

37 

1,100 

882 

80.1 

177 

16.0 

41 

111 

94 

84.6 

16 

14.4 

1 

78 

29 

37.1 

27 

34.6 

22 

1,029 

879 

85.5 

104 

10.1 

45 

287 

246 

85.7 

39 

13.5 

2 

165 

143 

86.6 

9 

5.4 

13 

661 

486 

73.5 

60 

9.0 

115 

11,564 

9,326 

80.6 

1,360 

11.7 

858 

.0 

.0 

7.9 

.0 

14.7 


,0 


.0 

16.7 
2.2 

7.4 
3,7 


28.1 
4.3 


8.0 
17.4 


7.4 


•  Only  figures  for  Cook  County  outside  of  the  City  of  Chicago  are  given  htere. 

More  than  one-third  of  the  reported  births  were  in  these  20  counties. 
The  percentage  of  cases  having  a  physician  was  80.6  per  cent,  those 
having  a  mid-wife  11.7  per  cent,  those  without  "properly  qualified 
attendants  7.4  per  cent.  In  Putnam,  Will,  Lake  and  Cook  (outside  of 
City  of  Chicago)  Counties  the  percentages  of  confinements  reported  with- 
out skilled  attendants  were  28.1  per  cent,  17.4  per  cent,  16.7  per  cent 
and  14.7  per  cent  respectively. 

The  nursing  care  at  the  time  of,  and  immediately  following,  con- 
finement is  of  almost  equal  importance  as  the  character  of  attendant. 
The  needs  of  both  mother  and  baby  during  the  first  few  days  following 
confinement  require  constant  attention  to  prevent  the  development  of 
complications  that  would  endanger  the  life  of  both  the  mother  and 
babe.  This  care  is  best  furnished  by  skilled  nurses.  In  594  home 
confinement  cases  found  in  the  Commission's  study  of  wage-earning 
blocks  in  Chicago,  217,  or  36.5  per  cent,  had  some  kind  of  special 
nursing.  In  70  of  these  a  private  nurse,  in  130  a  visiting  nurse,  and 
in  17  an  attendant  of  some  kind  gave  nursing  care.  In  addition  to  the 
594  home  cases,  there  were  95  hospital  cases  where,  of  course,  nursing 
care  was  provided.  In  other  words,  in  45.1  per  cent  of  the  691  cases 
nursing  care  in  some  form  was  employed.'*^ 

Besides  good  obstetrical  care  and  nursing  care — best  provided  in 
hospitals,  not  in  the  average  home — public  health  officials,  doctors  and 
others  who  have  given  this  question  most  thoughtful  consideration  agree 
that  there  is  need,  also,  for  skilled  advice  during  pregnancy.  Some 
prenatal  care  is  being  provided  in  Chicago  by  the  Infant  Welfare 
Society  which  maintains  a  prenatal  clinic,  by  the  Visiting  Nurse  Asso- 

"  Complete  information  was  received  from  691  of  the  695  confinement  cases. 


?> 


65 

elation,  and  by  the  Central  Free  Dispensary  and  two  or  three  similar 
organizations  which  maintain  out-patient  obstetrical  departments.  Less 
is  being  done  in  the  State  outside  of  Chicago  for  the  visiting  nursing, 
dispensary  and  infant  welfare  organizations  are  not  so  extensively 
developed. 

The  experience  of  the  Metropolitan  Insurance  Company  in  provid- 
ing nursing  service  in  maternity  cases  is  valuable. 

"During  1911,  there  were  70.1  deaths  from  causes  associated 
with  child-birth  per  100,000  white  female  policyholders  between  the 
ages  15  and  44.  In  1916  the  death  rate  from  these  conditions  was  re- 
duced to  62.6  per  1000,000,  a  decrease  in  the  rate  of  10.7  per  cent. 
Among  colored  female  policyholders  the. rate  for  mortality  from  causes 
connected  with  childbearing  was  88.4  per  100,000  in  1911.  This  rate 
was  reduced  to  a  figure  of  70.4  in  1916,  a  decline  of  20.4  per  cent.  The 
consistent  decline  in  mortality  from  puerperal  conditions  and  diseases 
among  both  white  and  colored  policyholders  is  in  marked  contrast  to 
the  mortality  figures  for  the  general  population  included  in  the  Reg- 
istration Area  for  deaths  in  the  United  States.  In  the  five  years  prior 
to  1916,  the  death  rate  from  the  diseases  connected  with  childbearing 
had  been  practically  stationary."*^ 

The  importance  of  good  maternity  care  is  shown  by  the  results 
obtained  by  some  of  the  few  institutions  in  Chicago  that  are  giving 
attention  to  this  subject. 

The  Central  Free  Dispensary  gives  examinations  and  registers  cases 
in  early  pregnancy.  These  cases  are  then  followed-up  and  observed  and 
advised  by  a  visiting  nurse.  Eeexaminations  are  made  by  the  physician 
as  needed.  Physician  and  nurse  attend  at  confinement.  After  con- 
finement the  case  is  referred  to  the  Visiting  Nurse  Association  for 
nursing  care  and  later  to  the  Infant  Welfare  Society.  From  April  1, 
1908  to  December  31,  1918  the  Central  Free  Dispensary  cared  for 
4,344  home  confinements  with  only  4  deaths. 

Working  along  similar  lines  the  Dispensary  of  the  Chicago  Lying- 
in  Hospital  during  the  first  19  years  of  its  operation  cared  for  24,764 
confinements,  with  only  8  deaths  among  the  patients  who  came  ex- 
clusively under  its  care.  Eecords  of  this  kind  show  the  possibility  of 
reducing  deaths  from  childbirth  and  stand  in  contrast  to  the  records  for 
the  City  as  a  whole  where  deaths  from  childbirth  amounted  in  1917,  as 
shown  above,  to  between  5  and  6  per  1,000.  These  figures  emphasize 
both  the  need  for  and  the  successful  results  of  good  maternity  care. 

(7)   Infant  Welfare  Worh. 

Consideration  of  the  problein  of  the  preservation  of  the  life  of  the 
child  follows  naturally  the  consideration  of  the  problem  of  conserving 
the  life  of  the  mother.  One  of  the  chief  difficulties  in  studying  the 
infant  welfare  problem  is  the  deficiency  in  information  concerning  infant 
mortality  rates.     Illinois  is  not  a  "registration  state^'  for  births.     In 

"  Quoted  from  "Visiting-  Nursing  and  Life  Insurance,"  by  Lee  K.  Frankel  and 
Louis  I.  Dublin,  Quarte^'ly  Publications  of  the  American  Statistical  Association, 
June  1918,  p.  38. 

— 5  H  I 


66 


Chicago  where  a  most  active  effort  has  been  made  to  secure  complete 
reports,  the  Health  Department  does  not  claim  to  get  more  than  75  per 
cent  of  the  entire  number.  Under  the  circumstances  no  comparisons 
can  be  made  of  deaths  of  children  under  one  year  of  age  and  the  number 
of  "live  births"  for  any  places  in  the  State  except  Streator,  Quincy,  and 
Peoria  where  the  Children's  Bureau  has  recently  completed  investigations 
with  results  making  such  comparisons  possible.  The  death  rates  per 
1,000  live  births  were  found  to  be  83.9,  82.8  and  101.6  in  these  three  cities 
respectively.^^ 

Unfortunately,  also,  until  1918  Illinois  was  not  a  registration 
state  for  deaths.  Until  detailed  mortality  figures  are  available  for  the 
year  1917-1918  it  will  not  be  possible  to  compare  the  deaths  of  children 
under  one  3'ear  of  age  with  the  estimated  total  population.  For  some 
years,  however,  eight  of  the  cities  have  had  sufficiently  complete  reports 
of  deaths  to  be  included  in  the  registration  area.  Though  they  are 
of  limited  value  because  of  the  margin  of  error  in  the  estimates  of 
population  and  the  varying  percentage  of  those  under  one  year  of  age 
in  the  total  population,  comparisons  of  deaths  of  infants  and  total  popu- 
lation are  presented  for  these  eight  cities  in  the  following  table.  The 
data  are  taken  from  the  Census  Mortality  Statistics  for  1916. 


City. 


Population. 


Deaths 
tinder  1  year. 


Rate  per 

10,000 

population. 


Aurora 

Belleville... 

Chicago 

Decatur 

Evanston... 
Jacksonville 

Quincy 

Springfield.. 

Total... 


34,204 
21,149 
,497,722 
39,631 
28,721 
15,481 
36,798 
61,120 


2,734,826 


55 
39 
6,910 
75 
44 
26 
57 
119 


16.08 
18.43 
27.66 
18.92 
15.32 
16.79 
15.38 
19.46 


7,325 


26.78 


The  marked  differences  in  these  rates  may  result  from  a  variety  of 
influences  in  addition  to  those  mentioned  above.  The  Children's  Bureau 
has  shown  that  medical  care  at  birth,  nursing  attention,  character  of 
feeding,  nationality  of  mother,  number  and  frequency  of  births,  earn- 
ings of  father,  and  other  similiar  influences  diow  a  close  correlation  with 
infant  mortality  rates.  The  following  table  shows  how  the  mortality 
rate  declines  as  the  family  income  increases.  The  table  snows  the 
combined  figures  for  the  eight  cities  in  which  the  Children's  Bureau 
made  special  investigations.^* 

"The  Commission  is  indebted  to  the  Children's  Bureau  for  permission  to  use 
these  unpublished  data. 

"The  eig-ht  cities  where  surveys  were  conducted  are:  Johnstown,  Pa.,  Man- 
chester, N.  H.,  Saginaw,  Mich.,  Waterbury,  Conn.,  Brockton,  Mass.,  New  Bedford, 
Mass.,  Akron,  Ohio,  and  Baltimore,  Md. 


67 


Earnings  of  father. 


Infant  mortality 
rate.* 


Less  than  $550  a  year. 

$550  to  $849 

$850  to  $1,049  

$1,050  to  $1,249 

$1,250  and  over 


162.5 

119.8 

95.0 

61.7 

62.5 


•  See  Report  of  CMef  of  Children's  Bureau,  1917,  pp.  14-15. 

It  is  not  surprising  that  there  is  a  close  correlation  between  infant 
mortality  rates  and  earnings,  for  the  family  income  determines  to  a 
large  extent  the  conditions  under  Avhich  the  infant  lives,  such  as  housing, 
character  of  food,  and,  in  the  main,  the  medical  and  nursing  care,  unless 
the  latter  are  furnished  as  a  free  service. 

It  is  generally  asserted  that  the  death  rates  of  infants  are  abnor- 
mally high,  and  that  there  are  great  possibilities  of  reducing  these  death 
rates,  if  the  known  methods  of  care  were  generally  applied.  All  "Baby 
Saving  Campaigns"  are  based  upon  this  assumption.  Within  broad 
limits  the  truth  of  this  assumption  cannot  be  doubted,  but  the  extent 
to  which  prevention  can  be  carried  varies  greatly  with  the  disease.  This 
is  shown  by  brief  reference  to  scarlet  fever,  measles,  whooping  cough, 
diplitheria,  and  diarrhea  and  enteritis,  which  are  '^children's  diseases." 

The  records  of  the  Chicago  Health  Department  show  some  very  in- 
structive facts  concerning  these  diseases  and  the  possibility  of  reducing 
the  death  rates  from  them.  First,  in  the  case  of  scarlet  fever  the  records 
show  that  during  a  period  of  40  years  (1875-1916)  there  have  been 
recurring  waves  of  high  mortality  rates  at  periods  of  approximately  5 
years.  Apparently  those  children  who  are  unable  to  withstand  the 
ravages  of  the  disease  die  off  and  then  the  disease  subsides  until  a  new 
group  of  susceptible  children  comes  on.  Little  is  known  of  this  disease, 
so  that  prevention  is  confined  mainly  to  quarantine  methods.  The 
death  rate  in  Chicago  from  this  cause  was  0.64  per  10,000  in  1916. 
Second,  the  death  rate  from  diptheria  has  been  greatly  reduced  since 
1896  when  the  anti-toxin  was  first  introduced.  If  cases  are  discovered 
in  time  and  properly  treated,  the  fatalities  may  be  greatly  reduced.  The 
rate  for  Chicago  in  1916  was  3.15  per  10,000  population,  but  the  variation 
between  wards  was  from  0.53  to  10.44.  Third,  the  death  rate  from 
measles  runs  a  close  second  to  that  of  scarlet  fever,  which  proves  that  the 
disease  should  not  be  regarded  lightly.  The  rate  in  Chicago  in  1916 
was  0.52  per  10,000  as  compared  with  0.64  for  scarlet  fever.  Fourth, 
much  the  same  statement  may  be  made  for  whooping  cough  as  for 
measles.  The  rate  for  this  disease  in  1916  was  0.44  but  in  1917  it  was 
0.828  which  is  higher  than  the  rate  for  scarlet  fever. 

Fifth,  the  diseases  that  cause  the  greatest  number  of  deaths  among 
children  under  2  years  of  age  are  the  gastric  and  intestinal  diseases, 
among  which  diarrhea  and  enteritis  are  the  most  important.  In  1916 
the  Health  Department  found  that  3,450,  or  40.9  per  cent,  of  the  8,421 
deaths  of  children  under  2  were  due  to  diarrhea  and  enteritis.  Similar 
facts  have  been  found  in  other  localities  where  studies  have  been  made. 


68 

The  Children's  Bureau  found  in  Manchester,  New  Hampshire,  that 
38.4  per  cent  of  all  deaths  of  infants  under  1  year  were  caused  by 
enteritis.  The  disease  is  commonly  regarded  as  a  hot  weather  disease, 
as  the  death  rate  is  higher  during  the  three  hottest  months  of  the  year 
and  is  always  higher  during  summers  of  excessive  heat  than  during 
summers  of  normal  temperature.  Whether  the  cause  be  one  of  heat  or 
character  of  feeding,  or  both,  the  fact  can  be  clearly  demonstrated  that 
the  death  rate  is  highest  in  the  congested  wards,  and  in  wards  in  which 
the  foreign  population  is  concentrated.  During  the  hot  summer  of  1916 
the  Chicago  Health  Department  kept  a  spot  map  of  deaths  from  this 
disease  and  three  centers  were  clearly  discernable,  one  in  the  Seventeenth 
Ward  along  Milwaukee  Avenue,  another  west  of  the  Eiver  along  the 
south  branch  of  the  Eiver  running  west  to  Western  Avenue,  and  the 
third  in  the  neighborhood  of  the  Stockyards,  where  the  number  of  deaths 
was  very  great. 

It  is  generally  held  by  physicians  and  others  competent  to  know 
that  a  very  large  reduction  in  the  death  rate  from  this  disease  can  be 
effected.  In  fact,  the  Census  Department  has  shown  that  the  rate  per 
100,000  population  of  all  ages  for  the  registration  area  has  declined 
from  108.8  in  1900  to  65.6  in  1916.*^  The  death  rates  of  children  under 
two  years  of  age  from  enteritis  are  shown  for  the  ten  cities  with  500,000 
population,  or  over,  in  the  following  table. 

DEATH    RATES    PER    100,000    OF    POPULATION    FOR    CHILDREN    UNDER    2 
YEARS  FROM  ENTERITIS  IN  CITIES  OF   500,000  POPULATION.* 


Year. 


New- 
York. 

Chi- 
cago. 

Phila- 
delphia. 

St. 
Louis. 

Boston 

Cleve- 
land. 

De- 
troit. 

Balti- 
more. 

Pitts- 
burgh. 

Los  An- 
geles. 


1916... 
1915... 
1914... 
1913... 
1912... 
1911... 
1906-10 
1901-05 


58.1 

141.4 

88.3 

49.9 

49.4 

109.9 

129.3 

99.4 

117.  81 

72.2 

112.7 

90.0 

45.0 

62.9 

103.5 

97.0 

83.0 

97.6 

67.1 

131.1 

107.4 

61.3 

64.6 

108.1 

122.2 

101.5 

103.7 

73.5 

142.0 

100.6 

72.6 

72.9 

133.0 

106.0 

101.5 

134.8 

82.4 

139.1 

93.4 

69.1 

84.8 

140.4 

99.1 

91.5 

113.5 

92.6 

132.6 

118.0 

87,2 

106.4 

133.6 

98.6 

104.2 

130.3 

133.8 

138.  0 

133.5 

73.7 

99.2 

132.4 

102.8 

118.0 

169.1 

145.0 

104.4 

96.8 

62.8 

107.4 

104.0 

99.6 

129.4 

170.2 

29.1 
27.1 
30.8 
42.7 
29.3 
31.3 
35.9 
34.6 


•  Mortality  Statistics  1916,  p.  51. 

It  is  evident  from  these  figures  that  in  most  of  the  cities  there  has' 
been  a  decline  in  the  mortality  rate.  The  figures  do  not  furnish  a 
satisfactory  basis  for  comparison  of  rates  between  cities  because  of  the 
different  proportion  of  children  in  the  total  population.  In  this  con- 
nection, it  may  be  said,  however,  that  the  number  of  children  under  2 
years  of  age  per  100,000  population  in  these  cities,  according  to  the 
Census  of  1910,  was  as  follows:  New  York  4,349.6;  Chicago  4,208.5; 
Philadelphia  4,004.3;  St.  Louis  3,444.2;  Boston  3,865.1;  Cleveland 
4,619;  Detroit  4,273.3;  Baltimore  3,554.4;  Pittsburgh  4,420;  Los 
Angeles  2,825.5.  If  these  ratios  of  children  under  2  years  of  age  have 
remained  approximately  constant,  it  is  evident  that  the  showing  of 
Chicago  is  not  as  favorable  as  for  the  four  cities  having  a  higher  ratio 

*' Seventeenth  Annual  Report  of  U.  S.  Census  Mortality  Statistics,   1916,  p.  50. 


69 

of  children  under  2  years  of  age  than  Chicago.  New  York  had  an  annual 
average  for  1901  to  1905  of  145  per  100,000,  which  was  reduced  to  58.1 
in  1916.  Chicago,  on  the  other  hand,  had  an  increase  from  104.4  to 
141.4  for  the  same  dates.  It  should  be  said,  however,  that^the  summer 
of  1916  was  exceedingly  hot  in  Chicago  and  the  rate  of  141.4  was  con- 
siderably in  excess  of  the  rate  for  1915  (112.7).  However,  in  view  of 
the  fact  that  these  estimates  are  made  on  the  same  basis,  and  that  all 
except  Chicago  and  Detroit  show  a  decline  in  rate,  it  would  seem  con- 
clusive that  there  is  need  for  more  effective  treatment  of  this  disease 
than  has  as  yet  been  applied. 

Belief  that  the  death  rate  can  be  reduced  has  led  to  the  baby  saving 
campaigns  especially  during  the  summer  months.  The  need  for  work 
of  this  kind  is  not  confined  to  these  months  as  may  be  seen  from  the 
following  figures : 

MONTHLY  DEATHS  FROM  DIARRHEA  AND  ENTERITIS  FOR  1917  AND  1918. 


Month. 


1917 


1918 


January. . . 
February. . 

March 

April 

May 

June 

July 

August 

September. 
October. . . 
November . 
December. 


166 
147 

*257 
208 
158 

*142 
200 

*570 
379 
327 
263 


*  Fig-ures  for  5  weeks.     Other  figures  are  for  4  weeks. 

While  the  number  of  deaths  is  higher  in  August  and  September 
than  the  monthly  averages,  the  above  figures  show  that  the  number  of 
deaths  in  otHer  months  is  also  large.  In  the  light  of  these  facts,  this 
disease  cannot  be  regarded  as  merely  a  hot  weather  disease.  So  far  as 
care  is  an  important  factor  in  reducing  the  death  rate,  these  figures 
point  to  the  need  for  constant  care  throughout  the  entire  year. 

Confidence  in  the  possibility  of  preserving  the  lives  of  babies  has  led 
d,  number  of  organizations,  both  private  and  public,  to  direct  their 
energies  into  this  work.  The  Elizabeth  McCormick  Memorial  Fund 
is  engaged  primarily  in  an  educational  campaign.  This  organization 
collects  and  distributes  literature  that  will  help  to  spread  information 
concerning  more  intelligent  feeding  and  care  of  children.  The  Infant 
Welfare  Society  is  organized  very  largely  for  the  purpose  of  caring  for 
children  under  two  years  of  age.  It  was  organized  in  1911.  The  organ- 
ization maintains  Infant  Welfare  Stations  in  various  sections  of  the 
City,  locating  them  where  the  need  is  greatest.  In  1917,  it  employed 
30  nurses.  Conferences  are  held  twice  a  week  at  the  Infant  Welfare 
Stations.  The  mothers  bring  their  babies  to  the  conferences  and  they 
are  carefully  examined  by  the  attending  physician.*^     If  the  physician 

46  Physicians  are  employed  to  make  the  examinations  at  the  conferences  at  the 
Infant  Welfare  Stations. 


70 


I 


discovers  that  a  child  is  not  developing  properly,  he  instructs  the  mother 
as  to  feeding  and  care.  The  nurses  visit  the  homes  and  show  the  mothers 
how  to  care  for  their  children.  The  following  summary  from  the 
annual  Eeport  of  the  Society  for  1917  shows  the  amount  of  work  done. 

Number  of  conferences  held o'l  cf 

Total  number  of  babies  cared  for no'lno 

Visits  made  in  the  homes  by  nurses 72,973 

The  records  of  the  Society  show  that  the  mortality  of  babies  coming 
under  the  care  of  its  physicians  and  nurses,  has  declined  from  4.2  per 
cent  in  1911  to  2.2  in  1918.  The  Visiting  Xurse  Association  cooperates 
in.  this  work  but  does  not  confine  its  attention  to  children.  In  fact 
this  organization  turns  many  cases  found  in  need  of  care  over  to  the^ 
Infant  Welfare   Society. 

The  City  Health  Department  operates  4  Infant  Welfare  Stations. 
During  the  summer  months  the  149  school  nurses  are  put  into  the  child 
welfare  work  through  the  Department's  own  stations  and  in  cooperation 
with  the  Infant  Welfare  Society.  The  most  congested  districts  and 
localities  showing  at  the  time  the  highest  death  rates  are  given  special 
service,  and  a  house  to  house  canvass  is  made.  Cases  of  sickness  thus 
located  are  cared  for  and,  if  the  Department  nurses  are  unable  to  do 
all  work  needed,  the  assistance  of  other  organizations  is  solicited. 

The  results  of  work  of  this  kind  are  not  always  easy  to  measure 
concretely,  but  the  Health  Department  found  that  comparing  the  sum- 
mers of  1912  and  1913  the  increase  in  the  death  rate  of  children  under 
2  years  of  age  from  enteritis  during  the  hot  summer  of  1913  in  the 
congested  wards  where  as  many  as  1,000  calls  had  been  made  by  the  nurses 
was  less  than  in  the  wards  not  so  covered.  The  Department  figures  are 
as  follows: 


Death  rate  per  1,000  from  enteritis. 

Year. 

Wards  having  1,000  *     Wards  not 
or  more  calls.      r        covered. 

1912.' .-^ 

19.4 

20.0 

0.6 

8.8 

1913 

10.7 

Increase  per  1,000, 1913  over  1912 

1.9 

These  figures  show  an  increase  in  mortality  rate  of  3.1  per  cent  in 
wards  where  nursing  care  was  given  and  21.6  per  cent  in  wards  where 
similar  service  was  not  furnished.  Considering  the  fact  that  the  nurs- 
ing service  was  furnished  in  the  most  congested  districts,  it  would  seem 
to  show  conclusively  the  possibilities  of  reducing  high  mortality  rates 
found  in  these  districts. 

Other  agencies  have  obtained  similar  results  from  nursing  care  of 
this  kind,  not  only  in  reducing  infant  mortality  rates  but  in  reducing 
mortality  rates  generally  of  those  who  receive  the  service.  The  most 
conspicuous  example  of  service  of  this  character  furnished  by  a  business 
concern  is  the  nursing  service  of  the  Metropolitan  Life  Insurance  Com- 
pany. Their  nurses  work  among  their  own  policyholders  who  are  in  the 
main  in  the  wage-earning  group. 


•^1 

The  1917  report  of  the  Company  on  its  welfare  work  shows  that 
the  death  rate  among  policyholders  declined  6.8  per  cent  for  all  ages 
between  1911  and  1916.  The  rate  declined  11.7  per  cent  for  the  ages 
1  to  4 — the  largest  decline  being  22.2  per  cent  for  those  1  year  of  age. 
While  the  company  has  furnished  a  large  amount  of  nursing  service  it 
has  also  carried  on  in  connection  with  this  service  a  wide-spread  campaign 
of  education  by  publishing  and  distributing  leaflets  on  child  care. 

Work  similar  to  that  described  above  is  being  carried  on  to  some 
extent  in  some  of  the  other  cities  and  towns  of  the  State.  Several  organ- 
izations have  been  found  that  devote  part  of  their  attention  to  this 
problem.  There  are  about  100  public  health  nurses  outside  of  Chicago 
and  a  majority  of  these  devote  a  part  of  their  time  to  infant  welfare 
work. 

(8)   Medical  Care  of  School  Children. 

The  children  of  to-day  will  be  the  workers  of  the  next  generation. 
Their  efficiency  and  mode  of  life  then  as  well  as  their  health  while 
pupils  will  depend  to  no  small  extent  upon  the  medical  care  and  super- 
vision provided  by  the  school  authorities.  Hence  the  importance  of  the 
medical  inspection  and  care  of  school  children  in  combating  disease  and 
conserving  health. 

Health  authorities  have  come  to  agree  that  if  workmen  are  entitled 
to  a  safe  place  in  which  to  work  and  to  protection  against  health  hazards, 
children^  especially  under  a  compulsory  school  attendance  law,  are 
entitled  to  a  safe  place  in  which  to  study  and  to  freedom  from  contact 
with  those  with  communicable  disease.  Moreover,  they  agree  that  if 
it  is  well  to  locate  physical  defects  in  workmen  so^  that  in  so  far  as 
possible  these  may  be  remedied,  it  is  well  to  ascertain  the  physical 
defects  of  school  children  so  that  they  may  receive  needed  treatment.  A 
resolution  adopted  by  American  boards  of  health  at  the  Conference  of 
State  and  Provincial  Boards  of  Health,  Los  Angeles,  California,  in  July, 
1911,  expresses  the  position  taken  with  reference  to  this  matter.  The 
resolution  adopted  reads  as  follows : 

"We  endorse  legislation  providing  for  the  medical  inspection  of 
schools,  because  extended  and  varied  experience  has  demonstrated  that 
efficient  medical  inspection  betters  health  iqonditions  among  school 
children,  safeguards  them  from  disease,  renders  them  healthier,  happier 
and  more  vigorous,  and  aims  to  insure  for  each  child  such  physical  and 
mental  vitality  as  will  best  enable  him  to  take  full  advantage  of  the  free 
education  offered  by  the  state. 

"It  is  our  judgment  that  every  law  providing  for  the  medical  in- 
spection of  schools  should  also  make  provision  for  frequent  inspections 
of  the  children  by  duly  qualified  school  physicians  to  detect  and  exclude 
cases  of  contagious  disease. 

"It  should  further  provide  for  annual  physical  examinations  of  all 
the  children  by  school  physicians  to  detect  any  physical  defects  which 
may  prevent  the  children  from  receiving  the  full  benefit  of  their  school 
work  or  which  may  require  that  the  work  be  modified  to  avoid  injury  to 
the  child. 


72 

"It  should  empower  school  physicians  to  conduct  examinations  of 
teachers  and  janitors  and  to  make  regular  inspections  of  buildings, 
premises  and  drinking  water  to  insure  their  sanitary  condition. 

"We  endorse  the  school  nurse  as  a  most  valuable  adjunct  of  medical 
inspection  and  believe  that  provision  for  the  employment  of  school 
nurses  should  be  included  in  each  law." 

Leading  educators  are  of  the  opinion  that  not  only  should  there  be 
medical  inspection  in  schools  for  the  detection  of  cases  of  contagious 
disease,  but  also  annual  physical  examinations  to  detect  other  diseases 
and  physical  defects  which  should  receive  treatment  and  to  indicate 
needed  adaptation  of  school  work;  sight  and  hearing  tests;  nursing 
service  not  only  in  the  schools  but  for  follow-up  work;  and  provision  in 
school  clinics  and  the  like  for  such  medical,  dental  and  ophthalmic 
treatment  as  is  needed  to  supplement  that  which  the  families  can  pro- 
vide privately  for  their  children — all  of  this,  of  course,  in  addition  to 
safe  and  sanitary,  properly  lighted,  heated  and  ventilated  school  build- 
ings, proper  provision  for  the  teaching  of  hygiene,  and  proper  pro- 
vision for  exercise  and  physical  training.*^ 

The  state  school  laws  in  Illinois  do  not  extend  beyond  a  require- 
ment for  teaching  physiology  and  hygiene,  the  provision  of  proper  hy- 
gienic, sanitary  and  safe  conditions  in  respect  to  school  buildings,  the 
elimination  of  the  common  drinking  cup,  and  provision  for  physical 
training  in  the  public  and  in  all  normal  schools.  Vaccination,  medical 
inspection,  nursing  service,  and  the  establishment  of  clinics  are  left  for 
local  action  under  general  powers  vested  in  the  health  and  school 
authorities. 

In  these  matters  Illinois  must  be  classed  with  a  minority  of  the 
states,  for  no  fewer  than  twenty-five  have  state  laws  relating  to  medical 
inspection  of  school  children.  Massachusetts  (1906  and  1908),  Louisi- 
ana (1908),  New  Jersey  (1909),  Colorado  (1909),  Xew  York  (1910 
and  1913),  Utah  (1911),  N'evada  (1917),  and  Xorth  Carolina  (1917) 
have  mandatory  laws  applying  throughout  the  state.  In  addition  to 
these  states  Washington  (1909),  Ohio  (1910),  Pennsylvania  (1911), 
West  Virginia  (1911),  and  Wyoming  (1915)  have  mandatory  laws 
applying  to  cities  of  certain  classes.  Twelve  other  states  have  permissive 
laws  setting  certain  standards  where  the  local  authorities  exercise  the 
ontion  they  have  in  the  matter.'*'* 

Such  investigations  as  the  Commission  has  been  able  to  make 
warrant  the  statement  that  "besides  instruction  in  hygiene,  in  at  least 
95  per  cent  of  the  communities  of  the  State  (rural  and  urban)  nothing 
systematic  is  done  to  promote  the  health  of  school  children,  except  in  time 
of  epidemics.  Then,  the  thing  usually  done  (depending  of  course  on 
the"  nature  and  prevalence  of  the  disease)  is  to  close  the  school.""*^ 
Those  communities  doing  more  or  less  in  a  systematic  way,  have,  perhaps, 
only  about  half  of  the  school  population  of  the  State. 

"  See  e.  g.,  Gulick  and  Ayres,  ''Medical  Inspection  of  Schools." 

"For  an  analysis  of  this  legislation  see  W.  G.  Reeder,   The  Present  Stat^ls  of 

Health   Work  in  the  Public   Schools   of  Illinois   in  Part   II   of  this   report.    Special 

Report  XIII. 

'••  See  above  reference. 


n 

Chicago  (the  second  city  in  the  United  States  to  provide  for  school 
inspection),  with  inspection  for  contagious  disease,  with  physical  ex- 
amination of  a  minority  of  the  public  school  pupils,  with  120  nurses  in 
the  schools  and  for  field  and  follow-up  work,  with  school  clinics,  school 
dentists,  and  an  ophthalmologist,  and  with  special  schools  for  the  tuber- 
culous, has  made  the  most  extensive  provision  found  in  this  State. 
However,  it  is  after  all  limited  as  compared  to  the  need.  The  provision 
is  made  by  the  Department  of  Health.  Outside  of  Chicago,  the  Com- 
mission has  found  school  physicians  in  30  cities.  In  9  of  these  and  in 
44  other  cities  one  nurse  (in  48  cases)  or  more  than  one  are  employed, 
but  in  only  about  half  of  these  cases  is  follow-up  work  done  outside  of 
the  schoolroom.  Xineteen  cities  other  than  Chicago  have  provision  for 
free  medical  and  dental  aid,  27  have  provision  for  free  medical  aid  only, 
and  20  for  free  dental  aid  only.  These  are  cities  and  towns.  In  the 
rural  schools  practically  nothing  is  being  done.  The  number  of  cities 
and  towns  making  provision  for  medical  supervision,  nursing  care,  and 
clinical  treatment  has  rapidly  increased  in  recent  years;  yet  there  is 
obviously  a  big  gap  between  what  educators  regard  as  highly  desirable 
and  what  some  of  the  progressive  states  are  requiring  and  what  is  being 
done  in  Illinois.  The  gap  is  really  greater  than  has  been  indicated  be- 
tween the  desirable  and  the  actual  provision  because  in  all  but  a  few 
cases  medical  examination,  nursing  service,  and  clinical  treatment 
supplementary  to  that  which  parents  can  provide  privately  are  not  com- 
bined into  a  well  developed  scheme.^° 

The  importance  of  well  developed  and  adequately  supported  service 
of  this  kind  in  the  schools,  is  in  no  way  better  indicated  than  by  the 
experience  of  Chicago.  In  1915,  Chicago  school  physicians  made  87,099 
visits  to  schools — 63,567  to  public  and  25,532  to  parochial  schools,  and 
1,128,232  inspections  of  children  were  made.^^  Of  these,  962,130  were 
preliminary  inspections  for  contagious  diseases.  In  addition  to  these, 
263,762  inspections  for  vaccinal  status  were  made. 

In  1915,  70,729  cases  of  contagious  diseases  were  found  and  21,730 
children  were  excluded  from  school  to  safeguard  the  health  of  others. 
In  the  same  year  physical  examinations  were  made  of  79,383  children. 
Of  this  number  37,356  were  found  to  be  defective  and  32,860  were 
advised  to  seek  treatment,  and  also  were  referred  to  the  school  nurses 
for  follow-up  work.  The  nature  of  the  defects  is  worth  presenting  in 
detail.  The  Annual  Review  Number  of  the  Department  of  Health 
may  be  quoted  as  follows : 

"A  tabulation  of  the  defects  on  35,166  pupils  shows  the  following: 
Malnutrition  804;  anaemia,  2,639;  enlarged  glands,  7,970;  goitre,  1,556; 
nervous  diseases,  340;  cardiac  diseases,  414;  pulmonary  diseases,  68; 
skin  diseases,  701;  orthopedic  defects,  171;  rickets,  372;  defective  vision, 
7,837;  other  diseases  of  the  eye,  1,076;  defective  hearing,  663;  dis- 
charging ear,  372;  defective  nasal  breathing,  2,603;  defective  palate, 

^  For  details  with  reference  to  the  cases  of  partial  provision,  inadequate  number 
of  nurses  for  the  pupils  enrolled,  and  the  small  amount  per  pupil  being  spent  on 
the  service  provided,  see  report  referred  to  above. 

*^  Facts  taken  from  Annual  Review  Number  (Bulletin  No.  6)  of  the  Depart- 
ment of  Health,  Chicago. 


u 


i 


Otl;  defective  teeth,  22,711;  hypertrophied  tonsils,  11,777;  adenoids, 
4,489;  tonsils  and  adenoids,  4,350;  mentality  poor,  1,196;  fair,  8,586. 

"During  the  year  263,762  out  of  286,802  pupils  were  examined  for 
their  vaccinal  status  in  432  public  and  parochial  schools;  65,344  re- 
quired vaccination;  34,824  received  vaccination;  25,727  secured  a  typical 
result.  The  parents  of  30,500  retfused  to  sign  consent  cards  for 
vaccination. 

"The  nurses  made  62,945  visits  to  schools,  of  which  53,644  were 
to  public  schools  and  9,301  to  parochial  schools;  775,970  pupils  were 
inspected.  Of  these.  189,506  were  preliminary  inspections  made  at 
beginning  of  school  term,  and  337,543  routine  inspections  made  during 
school  sessions.  In  doing  this  work  3,603  suspect  contagious  diseases 
were  found,  99,279  pupils  were  found  needing  attention,  and  2,207 
pupils  that  should  have  special  examination  for  Fresh  Air  Eooms." 

The  relative  number  of  Chicago  pupils  with  disease  and  defects 
requiring  care  in  order  that  disease  may  be  combated  and  health  con- 
served is  not  unusual.  In  fact  the  data  correspond  rather  closely  to 
estimates  for  a  typical  community  made  by  the  Committee  on  Health 
Problems  of  the  National  Council  of  Education.  Xor  is  the  problem 
indicated  a  city  problem  only;  the  number  of  diseased  and  physically 
defective  children  is  likely  to  be  larger  in  the  rural  community.^^ 

(9)   The  Physician  in  Industry. 

Except  for  incidental  references,  the  discussion  in  the  preceding 
sections  of  this  chapter  has  been  limited  to  the  health  activities  of  public 
and  semi-public  officers  and  institutions.  It  is  impossible  to  cover  all 
health  activities  exhaustively.  The  summary  undertaken  would,  how- 
ever, be  inadequate  unless  a  brief  statement  were  incorporated  relating 
to  industrial  medicine  and  surgery. 

There  are  in  Illinois  about  100  physicians  who  are  known  to  special- 
ize in  industrial  medicine  and  surgery.  By  far  the  greater  number  are 
in  Chicago  but  there  is  scarcely  a  city  of  any  industrial  importance  in 
the  State  in  which  one  or  more  are  not  found.  Nearly  all  of  them  com- 
bine employment  in  business  establishments  with  the  usual  private 
practice.  A  few  in  Chicago  do  industrial  work  for  a  number  of  small 
or  medium-sized  establishments  but  the  usual  practice  is  for  the  in- 
dustrial physician  to  take  employment  with  only  one  large  establishment, 
and  here  he  usually  has  the  assistance  of  from  one  to  three  physicians. 

What  is  known  as  industrial  medicine  and  surgery  is  comparatively 
new.  It  is  as  yet  by  no  means  standardized;  its  importance  in  combating 
disease  and  conserving  health  is  not  shown  by  a  large  accomplishment 
but  by  its  possibilities  as  revealed  by  what  has  been  accomplished  in  as 
yet  a  comparatively  few  establishments. 

In  not  a  few  establishments  departments  of  industrial  medicine 
and  surgery  have  grown  out  of  the  accident  problem.  In  a  relatively 
large  number  of  cases  whatever  provision  is  being  made  is  limited  to 
injury  cases  arising  in  employment.  But  once  physical  examinations 
have  been   introduced   and   adequate   care  given   in   accident   cases,   a 

"  For  estimates  made  for  the  National  Council  of  Education,   shown  by  urban 
and  rural  communities,  see  report  by  Reeder,  in  Part  II  of  this  report. 


much  larger  problem  and  much  larger  possibilities  have  been  revealed 
in  connection  with  sickness  and  physical  defects.  The  result  has  been 
that  in  a  considerable  number  of  instances  the  work  has  been  reorgan- 
ized and  extended  to  disabilities  in  general,  however  sustained.  In- 
deed, a  few  cases  have  been  found  where  the  service  in  connection  with 
accidents  has  become  little  more  than  an  incident  in  the  larger  plan 
developed.  And,  over  against  departments  with  a  development  thus 
described,  there  have  been  many  instances  in  which  medical  departments 
Avere  organized  to  deal  with  sickness  rather  than  accident  problems. 

Physical  examinations  may  disclose  the  applicants  who  would  be 
a  menace  to  others  because  of  contagious  or  infectious  disease  (which 
ought  to  be  and  may  be  reported  to  the  health  authorities),  or  those  for 
whom  no  suitable  jobs  can  be  found.  In  the  best  practice  jobs  are 
fitted  to  men;  reexaminations  are  made  as  needed  of  those  shown  by 
first  examinations  or  by  careful  supervision  to  be  in  poor  health,  or  a 
semi-annual  or  annual  examination  is  made  of  all  employees  as  well  as 
of  those  in  poor  health  as  needed ;  suitable  places  are  provided  for  those 
in  need  of  a  change  of  work;  medical  and  perhaps  personal  advice  are 
given  to  those  who  should  have  it;  and  care  is  exercised  to  see  to  it  that 
the  workmen  concerned  know  what  their  ph3^sical  condition  is.  In  a  few 
cases  applicants  for  work  are  merely  inspected  for  contagious  disease; 
medical  examinations  are  subsequently  made  to  see  that  workmen  have 
suitable  employment. 

In  respect  to  medical  care  the  usual  practice  of  the  industrial 
physician  is  to  give  only  "first  aid"  and  to  refer  sick  and  disabled 
employees  to  a  private  doctor  for  needed  treatment.  In  such  cases  the 
medical  department  developed  is  limited  to  a  staff  of  examining  and 
advisory  physicians  and  the  nursing  and  clinical  service  needed  for  first 
aid.  There  are,  however,  several  mercantile  and  manufacturing  estab- 
lishments, chiefly  in  Chicago,  which  have  made  more  extensive  provision 
because  of  the  situation  revealed  hy  experience.  Xeeded  operations  may 
be  arranged  for;  treatment  may  be  given  to  employees  when  unable  to 
pay  for  it;  visiting  nurses  may  be  emplo3'ed  to  care  for  the  sick  in  their 
homes;  in  at  least  two  large  and  well-known  establishments  dental 
service  has  been  introduced  because  of  the  importance  of  dental  care 
and  the  inability  or  neglect  of  employees  to  secure  it  in  private  offices; 
and  because  of  the  importance  of  diet  provision  may  be  made  for  suitable 
lunches  at  reasonable  prices  or  at  less  than  "cost  price." 

Industrial  medicine  on  this  plane  becomes  an  institution,  with  the 
employees  of  the  plant  as  the  unit,  to  conserve  health  and  to  prolong 
the  working  life.  Though  it  may  involve  some  disadvantages  which, 
however,  need  not  be  discussed  at  this  point,  it  has  in  it  great  possi- 
bilities for  the  prevention  of  physical  breakdown  and  scrapping  of  work- 
men. These  possibilities  are  all  the  greater  because  the  service  leads 
rather  directly  to  an  examination  into  the  causes  of  disease  and  to  an 
effort  to  remove  deficiencies  in  lighting,  heating,  ventilation,  washing 
and  toilet  facilities,  and  the  like  in  the  plant.  As  industrial  medicine 
develops  into  the  type  in  which  we  are  interested  here,  it  calls  for  the 
sanitary  engineer. 


The  possibilities  of  industrial  medicine  when  not  used  largely  or 
merely  for  the  selection  of  the  most  desirable  applicants  for  work,  are 
not  less  great  and  are  perhaps  greater  than  the  possibilities  of  the  medical 
supervision  of  school  children. 


In  the  ^bove  sections  an  attempt  has  been  made  to  indicate  briefly 
what  is  being  done  in  Illinois  to  combat  disease  and  to  conserve  health. 
It  is  recognized  of  course  that  the  services  given  by  the  doctor,  the 
hospital,  the  dispensary,  and  the  nurse  are  important  in  this  con- 
nection.    These  are  discussed  in  the  pages  immediately  following. 


77 


CHAPTER  III.     THE  CARE  OF  THE  SICK. 


In  the  chapter  immediately  preceding  something  has  been  said  of 
the  care  of  the  tuberculonS;,  of  the  treatment  of  those  afflicted  with 
venereal  disease,  and  of  infant  welfare  work.  In  this  chapter  the  results 
of  the  Commission's  investigations  of  medical  treatment,  the  public 
dispensaries,  hospitals  and  nursing  are  presented  in  summary  form. 

(1)  Medical  Treatment. 

■  According  to  the  census  made  by  the  American  Medical  Asso- 
ciation there  are  (September,  1918)  in  Illinois  some  10,909^  physicians 
licensed  to  practice  medicine.  This  is  one  physician  per  574  of  popu- 
lation as  against  one  to  each  691  in  the  United  States  as  a  whole  in 
1916.^  To  the  licensed  physicians  must  be  added  several  hundred  mid- 
wives — 574^  or  more  in  Chicago  and  small  numbers  in  other  parts  of  the 
State  where  foreign  groups  reside  in  considerable  numbers,  and  Christian 
Science  and  numerous  other  unlicensed  practitioners.  The  licensed 
physicians  are  distributed  fairly  well  over  the  State  according  to  the 
amount  of  general  medical  work  to  be  done.*  The  great  majority  of  the 
specialists,  and  also  of  the  unlicensed  practitioners  are  in  Chicago. 

Among  the  first  of  its  investigations  the  Commission  sought  data 
relating  to  the  economics  of  the  medical  profession.  Questionnaires 
were  delivered  to  8,939  licensed  physicians  in  practice.  The  questions 
related  to  their  training,  experience,  character  of  practice,  schedule  of 
fees,  charity  practice,  gross  income  from  practice,  professional  expenses, 
and"  net  income.  All  told  2,316  replies  were  received.  This  number 
was  not  as  large  as  desired  and  there  is  reason  to  believe  that  they 
were  not  entirely  representative  of  the  profession  as  a  whole.  In  secur- 
ing these  returns  the  cooperation  of  the  Illinois  State  Medical  Society 
was  of  distinct  assistance.  This  aid  brought  a  relatively  larger  number 
of  returns  from  those  who  have  membership  in  the  Society  which  is 
about  half  of  the  total  in  the  State.  This  has  caused  a  relative  excess 
of  returns  from  physicians  with  large  practice  and  the  larger  incomes. 
Hence  the  data  must  be  used  holding  in  mind  that  the  returns  are  not 
as  numerous  a-s  they  should  have  been  and  that  relatively  too  few  replies 
have  been  received  from  physicians  with  offices  in  working-class  com- 
munities in  Chicago  and  some  of  the  larger  cities  of  second  rank. 

1  As  given  in  list  prepared  by  the  American  Medical  Association.  Of  the  10,909, 
1,533  were  in  military  service. 

2  Statistics  Regarding  the  Medical  Profession,  p.  5.  Compiled  by  the.  Committee 
on  Social  Insurance,  American  Medical  Association.  According  to  this  report  (p. 
12),  Illinois  ranked  fifth  among  the  states  (sixth  if  the  District  of  Columbia  is  in- 
cluded), in  number  of  physicians  relative  to  population. 

3  The  State  Council  of  Defense  has  compiled  a  list  of  574  mid-wives  in  Chicago. 
"*  According  to  the   American   Medical   Association   the   number   of   persons    per 

physician  varied  from   439   in   Stark  to   1,121   in   Pope   County.      The  corresponding 
number  for  Cook  County   (total  number  of  physicians,   5,667)   was  497. 


m 

78  ^ 

The  medical  fees  in  general  practice  were  found  to  vary  considerably, 
but  not  greatly  from  one  part  of  the  State  to  another.  The  most  fre- 
quent charge  for  an  office  visit  was  $1.00,  for  a  house  call  $2.00,  with 
$1.Q0  added  for  a  night  call.  The  variations,  most  numerous  in  Chicago, 
were  chiefly  in  an  upward  direction.^  Since  the  investigation  was  made 
there  have  been  advances  of  rates  in  many  communities,  frequently  of 
fifty  per  cent. 

Naturally  the  gross  incomes  from  practice  vary  widely  with  the 
differences  in  experience,  abilit}^,  and  opportunities  of  the  physicians. 
So  do  their  professional  expenses  and  their  net  incomes.  The  gross 
incomes  from  practice,  with  salaries  for  teaching  and  fees  for  work  done 
for  insurance  companies  added  in  a  considerable  percentage  of  cases, 
were  found  to  average  $4,617  per  year  in  Chicago,  $5,490  in  other  cities 
with  populations  of  10,000  or  over,  and  $3,665  in  places  with  smaller 
populations.  For  the  reason  stated  above,  the  first  two  averages  must 
be  regarded  as  exaggerated.  The  other  should  be  approximately  correct, 
however,  for  the  returns  were  sufficient  in  number  and  sufficiently  repre- 
sentative to  give  a  correct  average. 

In  securing  the  relation  between  gross  income,  professional  ex- 
penses and  net  income,  only  those  returns  have  been  used  which  were 
evidently  made  from  the  accounts  which  were  said  to  be  kept.  Hence, 
only  790  of  the  2,316  returns  have  been  accepted.  In  Chicago  the  pro- 
fessional expenses  averaged  35.7  per  cent  of  the  gross  income,  in  other 
cities  with  populations  of  10,000  and  over,  34.5  per  cent,  in  smaller 
places,  34.1  per  cent.  The  net  incomes  averaged  $3,296  in  Chicago, 
$4,290  in  Peoria,  Springfield  and  the  other  cities  of  second  rank,  and 
$2,892  in  the  smaller  places.  Here  again,  of  ^^rse,  the  averages  for 
Chicago  and  cities  of  second  rank  are  exaggerated  because  of  the  in- 
clusion of  too  few  of  those  with  practice  largely  confined  to  the  poorer 
residents  of  their  localities.  Moreover,  the  averages  are  based  upon  a 
comparatively  small  number  of  returns  and  should  be  used  accordingly. 
It  would  appear,  however,  that  the  net  incomes  realized  from  the  licensed 
practice  of  medicine  are  not  excessive  in  view  of  the  ability  and  extensive 
and  expensive  training  required  and  the  conditions  under  which  the  work 
is  done.^ 

Thus  far  only  averages  of  gross  and  net  incomes  have  been  given. 
Additional  data  may  be  desired,  and,  hence,  are  presented  in  the  follow- 
ing tables.  The  first  shows,  by  specified  groups,  the  gross  earnings  from 
practice  reported  by  2,316,  the  second  the  net  incomes  realized  by  790. 

'  The   following   tabulation   shows   the   variations    in   fees   for   office   visits    and 
day  calls : 

Number  reporting  Number  reporting 

Rate.  for  office  visits.  for  day  calls. 

50   cents    15  1 

75    cents    7  1 

1100    561  66 

1-50    24  82 

2-00 120  491 

2.50    7 

3.00 :..:;:  -27  154 

Over  $3.00 3  34 

Total  reporting 757  836 

"For   some  data  bearing  upon   the   incomes   of   doctors   and   other   professional 
men,  see  Statistics  Regarding  the  Medical  Profession,  pp.  81-87. 


79 


GROSS  INCOME  FROM  PRACTICE  IN  1917  BY  POPULATION  OF  LOCALITIES. 


Gross  incomes  from 
practice. 


Number  in 
Chicago. 


Number  in 

cities  with 

Number 

Number 

10, 000  or 

in  places 

from 

Number 

over 

under 

unknown 

in  State. 

(Chicago 

10,000. 

places. 

1 

excepted). 

I 

Percent- 
age. 


Under  $500 

$      500  to  «      599 

600  to         699 

700  to         799 

800  to         899 

900  to  999 

1,000  to      1,199 

1, 200  to      1, 399 

1,400  to      1,599 

1,600  to      1,799 

1,800  to      1,999 

2, 000  to      2, 249 

2,  250  to      2, 449 , 

2, 500  to      2,  749 

2,  750  to      2, 999 

3,000  to      3,499 

3, 500  to      3,  999 

4,  000  to      4,499 

4,500  to      4,999 

5, 000  to      5, 999 

6,000  to      6,999 

7, 000  to      7, 999 

8, 000  to      8, 999 

9, 000  to      9, 999 

10,000  to    11,999 

12,000  to    13,999 

14, 000  to    15, 999 

16,000  to    17,999 

18,000  to    19,999 

20,000  and  over 

On  salary 

Income  not  reported 

Total 

Reporting  other  professional 
income 


14 
3 

5 
3 

9 

28 
13 

1 

6 

1 

2 

16 

6 
3 

2 
1 

5 
5 

13 
10 

1 

11 

3 

6 

2 

22 

21 

6 

21 

2 

50 

18 

13 

31 

1 

63 

22 

6 

27 

4 

59 

19 

8 

23 

2 

52 

48 

20 

38 

8 

114 

55 

19 

55 

8 

137 

24 

11 

28 

5 

68 

40 

17 

48 

9 

114 

22 

16 

29 

6 

73 

81 

44 

72 

11 

208 

42 

28 

71 

5 

146 

65 

29 

59 

11 

164 

48 

16 

48 

9 

121 

59 

44 

63 

4 

170 

55 

34 

48 

5 

142 

30 

23 

26 

1 

80 

21 

18 

12 

4 

55 

10 
27 

10 
22 

5 

12 

25 
62 

1 

19 

15 

2 

1 

37 

7 

10 

2 

19 

4 

4 

8 

19 

2 

} 

18 

6 
6 

18 
40 

1 

3 
2 

1 

84 

34 

59 

8 

185 

895 

486 

822 

113 

2,316 
969 

366 

179 

381 

43 

5.9 
2.9 
4.9 
3.1 
8.9 
6.3 
7.1 
5.2 
7.3 
6.1 
3.4 
2.3 
1.1 
2.7 
1.6 
0.8 
0.2 
0.2 
0.8 
1.7 
8.0 


There  is  little  of  what  may  be  called  "organized  practice  of  medi- 
cine" in  Illinois.  With  few  exceptions  families  call  physicians  of  their 
choice,  or,  calling  none,  neglect  needed  treatment,  buy  nostrums  or  take 
the  advice  of  friends  or  acquaintances  in  securing  medicines  required 
for  self-treatment.  Of  course  patent  medi.cines  are  extensively  pur- 
chased and  used.  The  Commission  has,  however,  made  no  investigation 
of  this  except  in  its  studies  of  wage-earning  and  other  families  in  Chicago. 
These  showed  what  was  known  without  investigation,  viz.  that  many 
resort  to  self-treatment.  Xor  has  the  Commission  attempted  to  make 
any  investigation  of  unethical  practices  in  medicine  by  licensed  physicians 
or  others.  Some  evidence  of  unethical  practice  has  come  to  the  attention 
of  the  Commission's  staff  of  investigators  when  using  the  records  kept  by 
social  agencies,  but  it  is  not  sufficient  to  warrant  any  conclusion  except 
that  at  times  advantage  is  taken  of  the  situation  to  charge  unreasonable 
fees,  especially  for  operations.  In  the  absence  of  data  collected  by  its 
staff,  the  Commission  may  quote  from  an  article  recently  published  by 
the  Director  of  Eegistration  and  Education.'^  His  department  is  charged 
with  the  enforcement  of  the  Medical  Practice  Act.     In  view  of  the  find- 


'' See   Joiirnal    of   the   American   Medical   Association,    November    16,    1918,    pp. 
1629-1630. 


80 


ings  of  his  staff  in  the  administration  of  this  act,  the  Director  writes, 
in  part,  as  follows : 

"They  (the  officers  of  the  Department)  found  an  army  of  adver- 
tising charlatans,  some  with  fixed  offices  and  others  appearing  'for  one 
day  only,'  making  extravagant  claims  of  curative  skill  in  handling  all 
diseases,  specialists  in  everything,  blatant  fakers,  robbing  the  poor  and 
ignorant,  preying  on  the  superstitions  of  gullible  foreigners     " 


*     * 


NET   INCOME    OF    790    ILLINOIS    PHYSICIANS    FOR   YEAR    1917. 


Gross  Incomes  from 
practice. 

Number  in 
Chicago. 

Number  in 
cities  with 

10, 000  or 
Qver 

(Chicago 
excepted). 

Number 

in  places 

under 

10,000. 

Number 

from 

unknown 

places. 

Number 
in  state. 

Percent- 
age. 

Under  $500 

5 
5 

4 

4 

3 

4 

14 

4 

14 

7 

11 

11 

17 

15 

7 

15 

23 

13 

12 

15 

9 

5 

1 

1 

6 

1 

2 

4 

5 

6 

12 

20 

24 

19 

22 

27 

27 

24 

20 

23 

18 

15 

14 

12 

6 

4 

1 

1 

2 

12 

6 

6 

8 

9 

13 

30 

38 

49 

41 

51 

57 

52 

55 

34 

57 

60 

45 

37 

49 

30 

16 

4 

5 

13 

5 

2 

2 

1 

3 

1.5 

1      500  to  $      599 

0.8 

600  to         699 

0.8 

700  to         799 

1.0 

800  to         899 

1 

2 

4 

11 

9 

10 

13 

16 

7 

13 

6 

14 

18 

13 

11 

21 

15 

6 

2 

4 

4 

4 

1.1 

900  to         999 

1 

1.6 

1,000  to      1,199 

3.8 

1,200  to      1,399 

3 
2 
5 
5 
3 
1 
3 
1 
5 
1 
4 

4.8 

1,400  to      1,599 

6.2 

1,600  to      1,799 

5  2 

1,800  to      1,999 

6  4 

2,000  to      2,249 

7.2 

2, 250  to      2, 499 

6.6 

2, 500  to      2, 749 

6.9 

2, 750  to      2, 999 

4  3 

3, 000  to      3, 499 

7.2 

3, 500  to      3, 999 

7.6 

4,000  to      4,499 

5.7 

4,500  to      4,999 

4.6 

5, 000  to      5, 999 

1 

6.2 

6,000  to      6,999 

3.8 

7, 000  to      7, 999 

1 

2  0 

8, 000  to      8, 999 

0.5 

9, 000  to      9, 999 

0.6 

10,000  to    11,999 

1 

1 

1 

1.6 

12,000  to    13,999 

0.6 

14,000  to    15,999 

1 

0.3 

16,000  to    17,999 

2 

0.3 

18,000  to    19,999 

1 

0.1 

20,000  and  over 

3 

0.4 

Total 

227 

210 

316 

37 

790 

100.0 

"They  found  a  motley  array  of  so-called  ^doctors,'  of  every  name 
and  cult  under  the  sun;  regulars,  homeopaths,  eclectics,  osteopaths, 
chiropractors,  napropaths,  spondylotherapaths,  mechanotherapaths,  neur- 
otherapaths,  electrotherapaths,  hydrotherapaths,  suggestive  therapaths, 
psycotherapaths,  naturotherapaths,  iridologists,  magnetic  healers,  re- 
ligious healers,  and  many  other  varieties     *     *     * 

"They  found  chains  of  doctors'  offices,  managed  by  real  estate  agents 
or  other  noiipractitioners  and  attended  by  licensed  physicians  who  were 
paid  from  $8  a  week  to  $35,  with  a  possible  commission  of  10  per  cent 
on  all  gross  business  over  $500  a  week;  the  manager  getting  all  the 
receipts,  paying  rent,  furnishing  light  and  providing  equipment;  *  *  * 
the  offices  using  common  literature,  apparently  printed  by  the  ton, 
distributed  by  hand  in  mail  boxes  and  front  yards,  and  bearing  the 
name  of  the  doctor  nearest  the  region  of  distribution,  who  for  himself 


81 

was  unable  to  read  the  circular  in  the  language  used,  and  so  knew 
nothing  of  the  glowing  promises  made  to  his  prospective  patients    *    *    * 

"Thej  found  doctors,  all  over  the  state,  who  were  guilty  of  unethical 
practices,  w^ho  were  known  to  be  quacks  of  the  worst  type     *     *     * 

"They  found  men  and  w^omen  in  many  places  in  Illinois  practicing 
medicine  without  license  and  defying  the  provisions  of  the  Medical 
Practice  Act/' 

These  statements,  it  should  be  carefully  noted,  are  with  reference 
to  persons,  trained  or  untrained,  licensed  or  unlicensed,  regulated  or 
unregulated,  offering  their  services  to  the  sick  and  injured.  There 
is  no  reason  to  think  that  the  situation  is  different  from  that  found  in 
most  of  the  other  states.  There  can  be  no  doubt  that  the  training  and 
ethical  code  of  the  great  mass  of  physicians  are  such  as  merit  only  com- 
mendation. The  quotations  are  designed  merely  to  indicate  that  there 
is  a  problem  in  the  behavior  of  a  relatively  small  but  not  negligible 
minority  which  remains  to  be  solved. 

Much  testimony  was  presented  to  the  Commission  at  its  hearings 
bearing  upon  the  adequacy  of  medical  facilities  and  attention.  It  showed 
considerable  disagreement  as  to  some  of  the  facts,  a  disagreement 
evidently  due  in  part,  however,  to  differences  in  what  is  meant  by 
"adequacy." 

It  is  evidently  true  that  the  services  of  the  general  practitioner  are 
available  to  all  who  seek  his  services  in  the  average  community  where 
the  population  is  fairly  stable  and  where  the  old-time  family  relation 
generally  obtains  between  the  sick  and  the  doctor.  Ability  to  pay  makes 
no  difference  to  the  doctors  who  do  "charity  work''  when  necessary  and 
seems  to  cause  little  disinclination  on  the  part  of  those  sick  and  unable 
to  pay  at  once  to  call  upon  the  physician  of  their  choice  in  cases  of  serious 
sickness.®  In  the  larger  centers,  and  especially  in  Chicago  where  both 
wage-earners  and  physicians  frequently  move  from  one  locality  to  an- 
other, the  situation  appears  to  be  somewhat  different.  Though  here  most 
physicians  freely  offer  their  services  when  called,  the  old-time  relation 
between  the  doctor  and  the  family,  and  especially  the  wage-earning 
family,  has  pretty  much  disappeared.  Social  workers,  including  the 
officers  of  charity  organizations  and  visiting  nurses,  are  almost,  if  not 
quite,  unanimous  in  the  statement  that  frequently  when  sickness  comes 
there  is  no  family  doctor  to  call,  there  may  be  hesitancy  to  call  strange 
physicians  because  of  inability  to  pay  at  once,  sometimes  payment  at 
once  is  demanded,  and  not  infrequently  the  sick  who  can  pay  fall  into 
the  hands  of  undesirable  practitioners.  Of  course  the  "poor  doctor" 
is  available  and  the  philanthropic  societies  and  dispensaries  stand  ready 

*  Of  2,014  physicians  reporting-  to  the  Commission  the  extent  of  their  ''charity- 
practice,"  only  78  reported  "none."  Of  the  others  407  reported  percentages  less 
than  five;  500,  five  but  less  than  ten;  512,  ten  but  less  than  fifteen;  122.  fifteen  but 
less  than  twenty;  147,  twenty  but  less  than  twenty-five;  114,  twenty-five  but  less 
than  thirty;  47,  thirty  but  less  than  thirty-five;  the  remaining  85,  various  percent- 
ages ranging  upward  from  thirty-five.  The  estimates  from  Chicago  physicians  are 
in  harmony  with  the  results  of  the  Commission's  family  studies.  The  smallest 
charity  practice  was  reported  by  physicians  located  in  places  with  populations  under 
10,000,  a  fact  explained  by  the  relatively  smaller  percentage  of  the  less  well-off  in 
their  communities. 

—6  H  I 


82 

to  supply  the  needed  treatment.  Under  existing  circumstances  these 
opportunities  are  frequently  unknown  or  available  only  after  delay  and 
perhaps  with  inconvenience.  Moreover  there  may  be  disinclination, 
except  in  an  emergency,  to  accept  service  tainted  by  charity. 

The  Commission  is  unable  to  state  how  far  medical  treatment  is 
inadequate  because  of  this  situation.  While  the  results  of  investigations 
elsewhere,  as  in  Rochester,^  showing  a  great  many  sick  and  without 
medical  treatment,  may  apply  equally  well  in  Illinois,  they  show  little 
with  reference  to  the  inadequacy  of  medical  facilities.  Illness  may  not 
be  of  such  character  as  to  require  medical  treatment  at  the  time;  the 
absence  of  treatment  may  be  due  to  neglect  on  the  part  of  the  family  or 
the  wide-spread  habit  of  self-treatment.  It  is  undoubtedly  true,  how- 
ever, that  there  is  much  more  neglect  of  needed  treatment,  much  more 
use  of  nostrums,  more  frequent  calling  of  unlicensed  practitioners,  more 
opportunity  for  the  charlatan,  and  more  opportunity  for  unethical 
practice  than  there  would  be  under  an  organized  system  of  medicine 
under  which  the  charges  of  the  physician  would  be  in  effect  definitely 
standardized,  and  the  sick  embraced  within  the  organization  could 
have  service  without  additional  cost  (over  dues  already  paid.) 

What  has  been  said  thus  far  concerning  the  adequacy  of  medical 
facilities  and  treatment  relates  to  the  availability  of  the  general  practi- 
tioner. The  important  deficiencies,  however,  are  found  in  the  absence 
in  many  cases  of  adequate  diagnostic  facilities  and  the  inability  of  the 
great  majorit}^  of  families,  whether  wage-earning  or  not,  to  secure  the 
service  of  specialists,  except  on  a  charity  basis.  Unquestionably  there 
is  a  big  gap  between  that  which  medical  science  has  made  possible  and 
that  which  the  average  family  gets  at  the  present  time. 

In  the  smaller  places  in  which  half  of  the  people  of  Illinois  live  there 
are  neither  good  diagnostic  facilities  nor  more  than  a  few  well-trained 
specialists.  Few  of  the  sick  can  afford  to  go  where  these  are  available. 
In  the  larger  places,  the  good  facilities  and  services  at  hand  are  made 
available  chiefly  to  charity  patients  through  dispensaries  and  hospitals 
and  to  the  very  well-to-do,  who  alone  can  pay  the  regular  schedule  of 
fees  charged  by  the  specialists  and  the  incidental  laboratory  fees. 

The  great  majority  of  families  have  only  the  service  of  a  general 
doctor.  As  a  rule  this  doctor,  under  the  individualistic  practice  of  medi- 
cine which  generally  prevails,  is  not  in  working  relations  with  specialists, 
and  does  not  use  the  diagnostic  facilities  to  be  found  in  the  community, 
most  likely  because  the  most  important  are  not  accessible  to  him.  In- 
dustrial physicians  have  stated  in  their  reports  to  the  Commission  that 
the  great  majority  of  wage-earners  when  in  need  of  operations  and  of 
treatment  by  specialists  have  not  had  the  service.  They  usually  state, 
also,  that  they  find  it  difficult  to  arrange  for  these  when  physical  examin- 
ation reveals  their  need.  As  has  been  pointed  out  above  some  of  the  large 
establishments  are  taking  steps  to  bridge  this  gap  so  far  as  their  em- 
ployees are  concerned. 

In  connection  with  what  has  been  said  with  reference  to  the  existing 
inadequacy,  it  should  be  stated  that  at  present  there  are  available  only 

»  See  Surveys  made  by  the  Metropolitan  Insurance  Company,  cited  above. 


83 

a  limited  number  of  well-trained  specialists.  The  supply  is  adjusted  to 
the  opportunity,  for  the  amount  of  such  practice  is  limited  and  for 
economic  reasons,  under  the  existing  organization  of  medicine. 

(2)   Hospital  Service  in  Illinois. 

In  the  provision  of  adequate  medical  service,  hospitals  have  an 
important  role.  With  the  development  of  modern  medicine  and  surgery 
they  become  a  more  and  more  necessary  part  of  the  community's  equip- 
ment for  the  efficient  care  of  the  sick.  Not  only  do  they  furnish  facilities 
for  medical  and  surgical  work  which  cannot  well  be  done  outside  a 
hospital's  walls  but  they  are  important  from  the  standpoint  of  economy, 
in  the  common  and  frequent  use  of  expensive  equipment  and  other 
diagnostic  and  therapeutic  facilities  not  otherwise  available  for  many 
doctors.  Economy  is  further  promoted  by  the  hospital  in  the  con- 
servation of  the  time  of  the  physician  which  it  makes  possible.  The 
physician  .who  serves  most  of  his  patients  in  the  hospital  can  make  far 
more  efficient  use  of  his  time  and  energy  than  can  he  who  treats  most 
of  his  patients  in  their  homes.  From  the  standpoint  of  the  patient  the 
hospital's  chief  value  lies  in  the  type  and  quality  of  service  which  it 
places  at  his  disposal  and  in  the  ready  access  it  may  furnish  to  whatever 
special  treatment  his  condition  may  demand.  In  brief,  the  hospital 
provides  the  basis  for  efficient  medical  service  because  it  is  organized 
for  that  purpose. 

For  purposes  of  classification,  hospitals  may  be  divided  into  two 
groups — general  hospitals  and  special  hospitals.  A  general  hospital 
is  one  to  which  patients  needing  practically  any  type  of  hospital  service 
are  admitted.  There  are  frequent  exceptions,  however;  few  general 
hospitals  admitting  patients  suffering  from  contagious  or  chronic  diseases. . 
A  special  hospital  is  one  organized  for  the  treatment  of  some  one  disease 
or  related  group  of  diseases,  such  as  tuberculosis  or  nervous  disorders, 
or  of  a  restricted  group  of  patients,  for  example — children. 

In  relation  to  their  support,  hospitals  may  be  either  public  or 
private.  In  this  sense,  a  public  hospital  is  one  which  is  supported  by 
the  state,  county  or  municipality  from  the  public  funds.  A  private 
hospital  may  be  privately  owned  and  operated  for  profit  or  it  may  be 
supported  in  part  by  contributions  and  endowments  and  conducted  not 
for  profit.  Most  public  hospitals  are  open  to  charity  patients  only. 
Most  private  hospitals  receive  both  pay  and  free  patients.  A  few  private 
hospitals  receive  some  public  support  in  return  for  treatment  of  indigent 
persons. 

In  order  to  learn  something  of  the  extent  of  the  hospital  facilities 
of  Illinois,  the  types  of  hospitals  existing,  the  number  of  patients  treated, 
the  rates  charged  for  hos})ital  service,  and  other  information  bearing 
upon  the  general  subject  of  its  investigations,  the  Commission  sent  a 
questionnaire  to  every  known  hospital  in  the  State.  All  but  a  few 
replied.  A  considerable  number  of  those  reporting  gave  incomplete 
information.  Frequently  the  information  obtained  did  not  check  with 
data  collected  by  the  American  Medical  Association  and  the  Modern 
Hospital..    Hence  the  statistics  given  below  are  incomplete  and  somewhat 


84 

inaccurate.     However,  the  percentage  of  error  is  not  great  enough  to 
affect  the  conclusions  which  may  be  drawn  from  them. 


HOSPITAL  BEDS  IN  ILLINOIS. 


Number 
of  beds  in 

general 
hospitals. 


Number 
of  beds  in 

special 
hospitals. 


Total. 


Chicago 

Illinois  (exclusive  of  Chicago) 

Total 


9,583 
7,018 


16,601 


2,608 
1,913 


4,521 


12, 191 

8,931 


21,122 


These  are  exclusive  of  state  hospitals  for  the  insane,  hospitals  in 
prisons,  jails,  and  reformatories,  and  hospitals  maintained  by  the  United 
States  Government  for  soldiers  and  sailors.  Taken  in  relation  to  popu- 
lation these  figures  show  that  Illinois  has  3.3  hospitals  beds  per  1,000 
inhabitants.  The  ratio  for  Chicago  is  4.4  and  for  the  rest  of  the 
State  2.2. 

In  point  of  numbers  and  in  relation  to  general  community  need, 
the  privately  conducted  general  hospitals  are  worthy  of  first  con- 
sideration. In  the  large  cities  these  hospitals  are  frequently  maintained 
by  corporations  organized  not  for  profit.  They  are  dependent  only  in 
part  on  fees  paid  by  patients;  contributions  and  income  from  invested 
funds  providing  a  considerable  part  of  the  money  necessary  for  their 
maintenance.  Most  of  these  hospitals  provide  accommodations  at  rates 
varying  from  expensive  private  room  charges,  through  lesser  rates  in 
two  and  four  bed  wards  to  moderate  fees  and  entirely  free  service  in  the 
larger  wards.  In  most  of  these  hospitals  the  private  room  patient  has 
his  own  physician  whose  fees  for  medical  or  surgical  service  are  entirely 
separate  from  the  fees  paid  the  hospital  for  board,  room,  laboratory 
work,  etc.  Patients  in  wards  are  frequently  known  as  "house  cases." 
They  do  not  as  a  rule  have  their  own  physician  but  are  given  medical 
treatment  by  some  member  of  the  hospital  staff  who  is  usually  not  com- 
pensated for  this  service.  The  one  fee  paid  for  a  ward  bed  covers  room, 
board,  medical,  and  general  nursing  service.  There  are  sometimes  small 
charges  made  to  cover  laboratory  and  operating  room  expense  and  in 
some  hospitals,  ward  patients,  who  are  able,  pay  the  attending  physicians 
small  fees. 

In  smaller  cities  there  is  less  likely  to  be  any  considerable  support 
of  hospitals  from  contributions  and  endowments.  Consequently  the 
hospitals  in  such  communities  must  meet  most  of  their  operating  expense 
from  fees  paid  by  patients.  This  means  that  a  smaller  percentage  of 
their  service  can  be  free  or  even  moderately  priced.  Eea^ardless  of  com- 
munity need,  a  hospital  must  meet  its  bills  or  close  its  doors. 

The  following  tables  show  the  distribution  of  beds  and  rates  for 
service  in  private  general  hospitals. 


85 


DIlSTRrBUTiON   OF   BEDS    IN    PRIVATELY   CONDUCTED    GENERAL, 

HOSPITALS. 


Number  of 
hospitals 
reporting. 

Number 

of  beds  in 

wards  of 

5  beds  or 

over. 

Number 
of  beds  in 

3  or  4 
bed  wards. 

Number 
of  beds  in  2 
bed  wards. 

Number  of 
beds  in  sin- 
gle rooms. 

Total. 

Chicago 

34 
27 

29 

1,593 
502 

71 

664 
311 
124 

484 

288 
85 

1,327 
813 

547 

4,068 
1,914 

827 

Cities  of  10,000  population  or 
over — exclusive  of  Chicago 

Towns  with  less  than  10,000 
population 

Total 

90 

2,166 

1,099 

857 

2,687 

6,809 

The  following  table  shows  the  rates  for  service  in  large  wards, 
small  wards  and  single  rooms. 


RATES  FOR  SERVICE   IN  PRIVATELY  CONDUCTED  GENERAL   HOSPITALS. 

CHICAGO. 


Type  of  service. 

Minimum  weekly  rate. 

Number  of 
hospitals. 

Five  bed  ward  or  larger 

$10.00  and  under 

14 

$10.50  to  $14.00 

17 

$15.00  to  $17.50 

6 

$10.00  to  $14.00 

Three  or  four  bed  ward 

37 
21 

$15.00  to  $19.00 

16 

$20.00  to  $21 .00 

2 

$12.00  to  $14.00 

Two  bed  ward 

39 
4 

$15.00  to  $19.25 

28 

$20.00  to  $24.50 

5 

$12.00 

Single  room 

37 
1 

$15.00  to  $19.25 

15 

$20.00  to  $24.50 

16 

$25.00  to  $29.00 

12 

$30.00  to  $31.50 

2 

46 

86 


RATES   FOR   SERVICE    IN    PRIVATELY   CONDUCTED    GENERAL.   HOSPITALS 

— Concluded. 

CITIES    OF    10,000    POPULATION    AND    OVER    EXCLUSIVE    OF    CHICAGO. 


Type  of  service. 


Minimum  weekly  rate. 


Number  of 
hospitals. 


Five  bed  ward  or  larger. 


Three  or  four  bed  ward . 


Two  bed  ward. 


Single  room . 


$10.00  and  under 
$10.50  to  $14.00.- 
$15.00  to  $17.50. . 

$  6.00  to  $  9.00. . 
$10.00  to  $14.00. . 
$15.00  to  $19.50. . 

$  8.00  to  $11.50.. 
$12.00  to  $14.00.. 
$15.00  to  $19.25.. 
$20.00  to  $21.00.. 

$  9.00  to  $14.00. . 
$15.00  to  $19.25. . 
$20.00  to  $24.50. . 
$25.00  to  $29.00.. 
$30.00  to  $31.50. . 


22 

12 

2 

36 
11 

23 

6 

<■ 

40 
13 

8 

8 

4 

33 
14 

23 

7 

0 

1 

45 

TOVP-NS   UNDER   10,000   IN   POPULATION. 


Type  of  service. 

Minimum  weekly  rate. 

Number  of 
hospitals. 

Five  bed  ward  or  larger 

$10.00  and  under , 

9 

$10.50  to  $14.00 

5 

$15.00  to  $20.00 

4 

$  6.00  to  $  9.00 

Three  or  four  bed  ward 

18 
4 

$10.00  to  $14.00 

11 

$15.00  to  $19.50 

9 

$20.00  to  $25.00 

1 

$  6.00  to  $11.50 

Two  bed  ward 

25 
6 

$12.00  to  $14.00 

6 

$15.00  to  $19.25 

9 

$20.00  to  $25.00 

5 

$  5.00  to  $14.00  ... 

Single  rooms 

25 
11 

$15.00  to  $19.25 

13 

$20.00  to  $24.50 

7 

$25.00  to  $29.00 

8 

$30.00  to  $35.00 

4 

• 

43 

These  tables  show  that  Chicago  has  a  much  larger  proportion  of 
beds  in  larger  wards  and  consequently  at  rates  more  easily  within  the 
reach  of  wage  earners  than  have  the  other  cities  of  the  State.  Cities 
of  10,000  or  over  have  a  much  larger  proportion  of  these  cheaper  beds 


87 

than  have  the  smaller  towns.  Eates  for  similar  types  of  service  in 
Chicago  and  the  other  cities  and  towns  of  the  State  do  not  vary  so  much 
as  might  be  expected.  In  some  instances  rates  are  lower  in  the  smaller 
cities  but  the  number  of  beds  available  at  these  lower  rates  is  very 
limited. 

PAY,    PART-PAY    AND   FREE    SERVICE    IN    PRIVATELY    CONDUCTED 

GENERAL.    HOSPITALS. 


Number  of 

Number  of 

Number  of 

Number  of 

pay 

part  pay 

free 

hospitals 

patients 

patients 

patients 

reporting. 

in  last 

in  last 

in  last 

fiscal  year. 

fiscal  year. 

fiscal  year. 

Total. 


Chicago 

Cities  of  10,000  population  and  over,  ex- 
clusive of  Chicago 

Towns  of  under  10,000  population — 

Total 


35 

35 
36 

73,789 

49,851 
12,312 

11,343 

3,379 

752 

20,766 

4,582 
468 

106 

135,952 

15,474 

25,816 

105,898 

57,812 
13,532 


177,242 


Stated  as  percentages  these  figures  yield  the  following : 


Pay 

patients— 

per  cent. 


Part-pay 

patients — 

per  cent. 


Free 

patients— 

per  cent. 


Chicago 

Other  large  cities 
Towns 


70 
86 
91 


11 
6 
6 


19 
8 
3 


The  number  of  hospitals  having  these  three  types  of  service  are 
shown  in  the  following  table. 


Number  of 
hospitals 
reporting. 


Having 
only  pay 
patients. 


Having 

some 
part-pay 
patients. 


Having 
some  free 
patients. 


Having 

no  free 

patients. 


Chicago 

Other  large  cities 
Towns 

Total 


35 

4 

26 

28 

35 

4 

26 

29 

36 

16 

14 

19 

106 

24 

66 

76 

7 

6 

17 


30 


From  the  above  tables  it  will  be  seen  that  Chicago  has  practically 
twice  as  large  a  percentage  of  part-pay  patients  in  its  privately  con- 
ducted general  hospitals  as  have  the  other  communities  of  the  State  and 
its  proportion  of  free  patients  is  more  than  twice  that  of  other  cities  of 
10,000  population  and  over,  and  more  than  six  times  that  of  towns  under 
10,000. 

In  Chicago,  only  one  privately  conducted  general  hospital  out  of 
46  reporting,  received  any  public  support.  Twenty  out  of  the  same 
number  reported  the  receipt  of  gifts  ranging  from  $250.00  to  $209,360.00. 
Twelve  of  the  46  receive  some  income  from  endowment  funds.  Of  43 
reporting,  21  stated  that  they  are  self-supporting.     In  cities  of  10,000 


88 

and  over,  exclu^!v^^^hicago,  19,  out  of  41  reporting,  received  public 
support  ranging  from  $98.00  to  $3,000.00  during  the  last  fiscal  year. 
Sixteen  out  of  39  reported  gifts  ranging  from  $72.00  to  $12,494.00. 
Nine  out  of  38  received  some  income  from  endoAvments.  In  towns  of 
under  10,000  population,  13  out  of  37  reported  receiving  public  support 
ranging  from  $15.00  to  $8,000.00.  Nine  out  of  36  received  gifts  rang- 
ing from  $10.00  to  $5,620.00.     Five  reported  small  endowments. 

These  figures  show  that  hospitals  in  the  larger  cities  of  the  State 
receive  substantial  financial  support  from  other  sources  than  patients,  but 
that  in  smaller  cities  and  towns  the  hospitals  to  a  far  greater  degree 
must  be  self-supporting.  To  accomplish  this  end,  they  must  very  de- 
cidedly limit  their  number  of  free  and  part-pay  patients. 

It  is  not  the  number  of  hospital  beds  in  a  community  but  the  use 
that  is  made  of  those  beds  that  measures  the  value  of  the  hospitals  to  the 
people.  The  unit  of  hospital  service  is  the  hospital  day.  A  hospital 
day  is  one  day  of  hospital  service  for  one  patient.  The  following  table 
shows  the  actual  service  of  the  privately  conducted  general  hospitals 
in  terms  of  this  unit  and  also  the  maximum  possible  amount  of  service, 
for  the  last  fiscal  year. 


Number  of 
hospitals 
reporting. 


Number 
of  beds. 


Actual 

number  of 

hospital 

days. 


Maximum 

possible 

hospital 

days. 


Percentage 
of  use  of 

maximum 
facilities. 


Chicago 

Other  large  cities 
Towns 

Total 


38 
33 

28 


99 


4,963 

2,650 

820 


8,333 


1.100,393 
541,080 
142,145 


1,783,618 


1,811,495 
930,750 
299,300 


3,041,545 


60.7 
58.1 

47.5 


58.6 


These  figures  indicate  that  in  the  38  Chicago  hospitals  reporting 
the  daily  average  number  of  vacant  beds  was  1,950  or  40  per  cent  of  the 
total  number  of  beds  available.*  The  33  hospitals  in  the  other  large  cities 
of  the  State  had  a  daily  average  of  1,071  empty  beds,  or  42  per  cent; 
while  in  towns  of  less  than  10,000  population  there  was  a  daily  average 
of  434  empty  beds  or  53  per  cent  in  the  28  hospitals  reporting.  If  the 
averages  shown  in  the  above  table  for  99  hospitals  are  representative  of 
conditions  throughout  the  State,  as  they  undoubtedly  are,  the  number 
of  hospital  beds  used  during  the  last  fiscal  year  bear  the  following  ratios 
to  1,000  population. 

Chicago 2.67 

The    State   exclusive   of   Chicago 1.22 

The   State   as  a  whole 1.95 

The  facts  just  presented  raise  the  question  why  there  is  such  a  high 
average  of  beds  not  used  ?  The  answer  may  be  sought  in  more  than  one 
condition.  Overbuilding  is  suggested,  but  it  is  interesting  to  note  in 
this  connection  that  according  to  statistics  compiled  and  published  by 
the  Modem  Hospital,  Illinois  has  but  62  per  cent  as  many  beds  per  unit 
of  population  as  has  the  United  States  as  a  whole.  For  a  part  of  the 
cause  we  must  go  back  to  the  problem  of  support.  A  hospital  can 
afford  to  keep  its  beds  filled  with  patients  who  pay  rates  which  cover  or 
more  than  cover  costs.     Free  and  part-pay  patients  are  cared  for  at  a 


89 

loss,  of  course.  Unless  the  deficit  their  treatment  entails  is  met  through 
public  or  private  contributions,  the  number  of  such  patients  which  a 
hospital  can  serve  must  be  limited.  Under  existing  conditions  there  are 
sure  to  be  empty  hospital  beds  and  sick  people  needing  hospital  care  at 
the  same  time  in  the  same  community.  Of  course  this  situation  applies 
to  the  pay  beds  in  private  hospitals.  Another  cause  of  this  condition, 
even  in  public  hospitals,  lies  in  hospital  organization  and  construction. 
Free  and  moderately  priced  beds  are  for  the  most  part  in  the  larger  wards. 
In  a  general  hospital  there  may  be  a  men's  medical  ward,  a  women's 
medical  ward,  a  children's  ward,  etc.  There  may  be  a  long  waiting 
list  of  patients  for  the  men's  medical  ward  and  at  the  same  time  empty 
bed's  in  the  women's  medical  ward  and  in  the  men's  surgical  ward.  If 
it  were  possible  to  construct  hospitals  with  all  or  most  of  their  beds  in 
single  rooms  and  to  maintain  them  at  a  moderate  cost,  and  some  hospital 
authorities  believe  it  can  be  done,  this  state  of  affairs  would  be  largely 
obviated,  and  the  use  of  the  hospital  would  much  more  nearly  approxi- 
mate its  capacity. 

There  are  in  the  State  a  number  of  general  hospitals  supported  by 
counties  and  municipalities  out  of  the  public  funds.  Eeports  from  seven 
of  these  gave  a  bed  capacity  of  2,936.  The  total  number  of  patients 
treated  during  the  last  fiscal  year  in  these  seven  hospitals  was  17,283. 
Service  in  four  of  these  seven  hospitals  is  entirely  free.  They  are  public 
charity  hospitals.  In  the  other  three  there  is  a  limited  number  of  beds 
in  private  rooms  and  small  wards,  available  at  rates  from  $10  to  $35 
per  week. 

In  addition  to  the  general  hospitals  described  above,  there  are  a 
considerable  number  of  special  hospitals  in  Illinois.  Of  the  20,341 
hospital  beds  in  the  State,  3,740  or  18  per  cent  are  in  special  hospitals. 
The  Commission  received  fairly  complete  reports  from  37  of  these 
special  hospitals.  Their  classification,  capacity  and  location  are  shown 
in  the  following  table. 

SPECIAL.  HOSPITALS. 


Type. 


Number. 

Number 

in 
Chicago. 

Number  in 
other  parts 
of  Illinois. 

Number 
of  beds. 


Tuberculosis 

Contagious 

Eye,  ear,  nose  and  throat 

Emergency 

Children's 

Nervous  and  mental 

Maternity 

Total 


9 

2 

7 

6 

4 

2 

4 

2 

2 

2 

4 

2 
3 

1 

6 
6 

6 

6 

37 

19 

18 

1,958 
506 
285 
133 
439 
235 
225 


3,779 


This  table  shows  that  the  number  of  these  special  hospitals  is  about 
evenly  divided  between  Chicago  and  the  rest  of  the  State.  The  disparity 
becomes  evident  when  we  consider  that  2,471  of  the  3,779  beds  in  this 
special  group  of  hospitals  are  in  Chicago  institutions.  A  much  higher 
percentage  of  the  service  in  these  special  hospitals  is  free  than  is  the 
case  with  the  general  hospitals. 


90 

The  data  the  Commission  has  been  able  to  collect  concerning  the 
hospitals  of  Illinois,  seem  to  indicate  in  the  first  place,  that  valuable  as 
is  the  service  which  the  hospitals  are  rendering,  the  hospital  facilities 
of  the  State  are  inadequate.  In  the  second  place,  because  of  high  main- 
tenance costs,  methods  of  distribution  of  beds  in  hospitals  and  perhaps 
for  less  obvious  reasons,  there  is  a  daily  average  use  of  less  than  60  per 
cent  of  the  hospital  beds  throughout  the  State.  The  small  wage-earner, 
needing  hospital  service  for  himself  or  for  some  member  of  his  family, 
can  hardly  aiford  individually  to  pay  a  rate  covering  the  actual  cost 
to  the  hospital  of  the  service  it  renders,  to  say  nothing  of  paying  the 
physician  for  his  services.  He  must  pay  a  rate  beyond  his  means,  accept 
charity  service  if  he  can  get  it,  or  go  without  hospital  service  altogether. 
From  the  standpoint  of  the  hospitals,  few  of  them  can  afford  to  provide 
beds  in  any  considerable  number  at  a  rate  which  wage-earners  seem  able 
to  pay. 

(3)  Dispensaries  and  Climes. 

In  the  larger  cities  many  poor  people  and  members  of  the  low 
income  group  obtain  medical  and  dental  service  in  dispensaries  and 
out-patient  departments  of  hospitals.  Generally  speaking,  dispensaries 
treat  ambulatory  patients  only.  Hence,  their  patients  come  for  relief 
from  minor  ailments,  for  treatment  of  diseases  in  their  incipient  stages 
and  of  diseases  which  do  not  confine  patients  to  their  beds  or  their  homes. 
This  group  embraces  a  much  larger  element  of  the  sick  than  does  the 
group  needing  hospital  care  or  the  services  of  a  physician  in  their  homes. 

The  dispensary  originated  and  to  a  large  extent  exists  to-day  as 
a  charitable  institution  whose  function  is  to  provide  medical  treatment 
for  the  poor.  Unlike  the  hospital,  the  dispensary  has  not  developed 
to  meet  the  needs  of  all  classes  in  the  community,  but  has  been  kept 
closed  to  a  large  element  of  the  population  who  are  unable  to  secure 
as  good  medical  service  as  do  those  poorer  people  to  whom  the  dispensary 
ministers.  However,  there  is  developing  a  tendency  to  make  dispensary 
service  available  for  people  who  are  not  indigent,  but  who,  nevertheless, 
are  not  able  to  pay  for  adequate  medical  treatment.  Some  of  the  older 
and  larger  dispensaries  are  connected  with  medical  and  dental  schools, 
and  their  clinics  like  those  of  hospitals  similarly  connected,  are  used  in 
teaching  medical  students.  Some  dispensaries  are  conducted  by  and  in 
connection  with  institutional  churches,  social  settlements  and  other 
social  institutions.  Some  are  out-patient  departments  of  hospitals  while 
others  are  separate  institutions  not  identified  with  hospital,  medical 
school,  church,  settlement  or  other  agency.  With  the  development  of 
industrial  medicine  and  surgery,  certain  industries  and  casualty  insurance 
companies  have  established  dispensaries  for  the  treatment  of  sick  or  in- 
jured employees  or  policyholders. 

Dispensaries,  like  hospitals,  may  be  divided  into  two  classes^ — 
general  and  special;  their  chief  difference  lying  in  the  fact  that  the 
general  dispensary  is  open  for  the  treatment  of  sick  people  irrespective 
of  type  of  disease  or  age  or  sex  of  patients  while  the  special  dispensary 
may  treat  some  one  disease  only,  as  tuberculosis  or  some  limited  class 
of  patients,  as  children. 


91 


Dispensaries  may  be  supported  in  one  or  more  of  several  ways.  In 
most  of  them  patients  who  are  able,  pay  small  fees  for  service,  medicines, 
special  appliances,  etc.  Some  have  small  endowments  or  receive  con- 
tributions from  persons  interested  in  this  form  of  philanthropy.  Others 
are  supported  as  an  integral  part  of  a  medical  school,  hospital,  church  or 
other  institution.  A  few  dispensaries  in  Illinois  are  supported  out  of 
the  public  funds.  As  a  rule,  dispensaries  have  not  been  well  supported, 
and  as  a  result,  have  not  been  able  to  render  the  efficient  service  their 
type  of  organization  makes  easily  possible. 

Eealizing  that  a  large  number  of  people,  especially  in  Chicago, 
receive  medical  treatment  in  dispensaries  and  that  among  this  number 
are  many  wage-earners  and  members  of  their  families,  the  Commission 
made  a  survey  of  the  dispensaries  of  the  State,  inquiring  into  the  volume 
of  their  medical  work,  its  nature,  their  equipment  for  its  efficient  per- 
formance, who  their  patients  are,  how  the  institutions  are  supported  and 
other  information  related  to  its  general  problem  of  sickness  among  em- 
ployed people.  Inasmuch  as  a  detailed  statement  of  the  results  of  this 
survey  is  published  in  Part  II  of  this  report,^°  it  will  suffice  here  to  set 
forth  only  the  general  conclusions  relating  to  the  care  of  the  sick. 

Ninety-eight  dispensaries  and  clinics  of 'various  types  were  located 
and  studied. ^^  Their  classification  and  distribution  are  shown  in  the 
following  table : 


, 

Chicago. 

Rest  of 
the  state. 

Total. 

General 

19 
44 

8 
27 

27 

Special 

71 

Total. 

63 

35 

98 

Outside  of  Chicago  there  are  general  dispensaries  in  Springfield, 
Evanston,  Oak  Park,  Eock  Island,  Peoria,  Rockford,  Argo  and  Blue 
Island.  The  special  dispensaries  existing  in  Illinois  are  divided  into  the 
following  classes : — ^Tuberculosis,  Eye,  Ear,  Nose  and  Throat,  Venereal 
Disease,  Obstetrics,  Diseases  of  Women  and  Children  and  Orthopedics. 
Outside  of  Chicago  practically  only  two  of  these  types  are  found — Tuber- 
culosis and  Orthopedic  dispensaries.  There  are  four  dental  dispensaries 
in  Chicago,  all  maintained  by  dental  schools.  Schools  of  osteopathy, 
naprapathy,  chiropractic,  etc.  maintain  dispensaries  in  relation  to  their 
clinical  teaching. 

The  work  of  the  more  important  of  the  special  dispensaries  has  been 
commented  on  earlier  in  this  report.  At  this  point  that  of  the  general 
dispensaries  alone  requires  brief  discussion. 

Most  general  dispensaries  are  organized  on  the  basis  of  medical 
specialties.  They  may  have  all  or  nearly  all  of  the  following  clinics 
or  departments — general  medicine,  surgery,  genito-urinary,  gynecology, 
dermatology,  laryngology,  ophthalmology,  neurology  and  paediatrics. 
Further  specialization  within  these  departments  is  found  in  some  dis- 

^"See  Special  Report  III. 

"  This  is  exclusive   of  those  maintained  by  city   physicians. 


92 

pensaries.  It  is  in  this  organization  of  the  dispensary  that  one  of  its 
chief  vahies  lies.  The  dispensary  patient  receives  the  benefit  of  the 
knowledge  and  skill  of  whatever  type  of  specialist  his  condition  may 
indicate. 

The  unit  of  dispensary  service  is  a  single  visit  or  treatment.  The 
98  dispensaries  studied  gave  a  total  of  approximately  860,000  treatments 
during  their  last  fiscal  year.  Of  these,  835,000  were  given  in  Chicago 
dispensaries.  With  an  average  of  four  treatments  per  patient,  which 
ratio  quite  generally  obtains,  about  215,000  persons  received  treatment 
in  dispensaries  in  Illinois  in  one  year.  This  is  about  3.4  per  cent  of  the 
population  of  the  State.  The  percentage  in  Chicago  would  be  eight.  In 
our  "block  studies"  of  3,003  families,  it  was  found  that  403  had  received 
dispensary  treatment  for  one  or  more  members  during  the  preceding 
twelve  months.  The  total  number  of  persons  in  these  families  was 
12,257,  the  number  of  persons  visiting  dispensaries  601,  or  4.9  per  cent 
of  the  same. 

Most  of  the  medical  service  in  dispensaries  is  given  by  physicians 
without  remuneration.  The  medical  dispensaries  of  Chicago,  exclusive 
of  tuberculosis  clinics,  were  found  to  have  on  their  staff  a  total  of  742 
physicians  of  whom  37  received  some  financial  compensation.  The 
small  fees  paid  by  patients  and  other  income  received  by  dispensaries  go 
to  meet  the  general  maintenance  expense  of  such  institutions.  Operating 
costs,  in  many  cases  exclusive  of  rent,  heat,  light,  etc.  vary  considerably. 
The  expenditures  of  nine  Chicago  dispensaries  giving  a  total  of  22,803 
treatments  in  one  year  averaged  44  cents  per  treatment. 

The  quality  of  medical  service  furnished  by  a  dispensary  depends 
upon  several  factors.  Of  primary  importance  is  the  stafi".  The  Com- 
mission made  no  inquiries  concerning  the  qualifications  of  physicians 
serving  on  dispensary  staifs.  Those  dispensaries  connected  with  high 
grade  medical  schools  probably  have  an  advantage  in  attracting  medical 
men  of  ability.  Equipment  for  modern j  scientific  diagnostic  and  thera- 
peutic procedure  is  essential  to  the  best  medical  service.  Such  equip- 
ment, including  x-ray  and  pathological  laboratory  facilities  is  frequently 
lacking  in  dispensaries,  or  if  not  lacking,  is  often  inadequate.  This 
greatly  affects  the  work  these  institutions  do.  In  some  dispensaries  there 
are  too  few  doctors  to  insure  that  each  patient  receives  the  time  and 
attention  his  case  may  demand.  Other  conditions  of  plant,  equipment, 
records,  organization,  etc.  all  making  their  contribution  to  the  quality 
of  service  a  dispensary  renders,  are  described  in  the  more  detailed  treat- 
ment of  the  subject  in  Part  II. 

As  dispensaries  have  increased  in  number  and  as  their  work  has 
increased  in  volume,  there  has  been  the  not  infrequent  criticism  on  the 
part  of  individual  physicians  and  medical  societies,  that  dispensaries 
bestow  medical  charity  upon  people  who  have  no  valid  claim  to  it  and 
who  can  well  afford  to  pay  for  medical  service.  As  long  as  dispensaries 
are  primarily  charitable  institutions  in  which  doctors  receive  no  financial 
compensation  for  their  services,  they  should  be  careful,  as  should  other 
charitable  agencies,  to  see  that  only  those  who  need  such  free  service, 
receive  it.     Dispensaries  differ  greatly  from  each  other  as  to  the  care  they 


93 

exercise  in  limiting  their  service  to  bona  fide  members  of  the  charity 
group.  Some  admit  every  applicant ;  others  make  financial  investigations 
of  practically  all  their  patients  and  exclude  all  whose  incomes  are  above 
a  fixed  standard;  still  others  fall  between  these  two  extremes,  taking 
what  seem  to  them  to  be  reasonable  precautions  to  keep  out  the  financially 
ineligible. 

Careful  investigations  have  been  made  at  different  times  in  Boston, 
New  York,  St.  Louis,  and  other  cities  of  a  considerable  number  of  dis- 
pensary patients,  to  ascertain  their  claim  to  free  medical  service.  These 
investigations  have  shown  that  only  a  small  percentage,  from  two  to  five, 
of  dispensary  patients  are  really  able  to  pay  for  the  medical  service  they 
seek  to  obtain  free  or  upon  payment  of  a  nominal  fee. 

In  our  study  of  2,869^^  families  in  Chicago  (charity  cases  excluded) 
it  was  found  that  511  families,  or  17.8  per  cent,  had  received  some  form 
of  dispensary  service  for  one  or  more  members  within  the  preceding 
twelve  months.  Budget  studies  made  in  North  Chicago,  and  investi- 
gations made  by  the  Bureau  of  Labor  Statistics  and  by  the  War  Labor 
Board  indicate  that  for  a  family  of  five  (man,  wife  and  three  children 
under  15)  an  income  of  $1,700  per  year  is  necessary  to  meet  all  normal 
family  expenses  including  average  sickness  costs.  Using  this  figure  as 
a  basis  of  classification  of  the  2,869  families,  we  find  that  1,717  had 
incomes  of  $1,700  or  over,  or  equivalent  sums  for  smaller  or  larger 
families,  as  against  1,152  with  smaller  incomes.  Of  the  511  families 
receiving  dispensary  service,  102  were  in  the  group  with  the  larger 
incomes  (with  a  minimum  of  $1,700  or  its  equivalent).  Of  these  102 
families,  24  were  given  service  in  municipal  tuberculosis  clinics,  infant 
welfare  stations  or  in  special  clinics  established  for  after-care  of  infantile 
paralysis,  which  institutions  for  obvious  reasons  do  not  limit  their  service 
to  any  economic  group.  This  leaves  78  families  in  the  higher  income 
group  receiving  medical  advice  and  treatment  in  dispensaries  which  in 
general  confine  their  service  to  people  of  very  limited  income.  These 
78  families  are  15.2  per  cent  of  the  511  families  with  dispensary  records. 

It  is  well  to  bear  in  mind,  however,  that  the  type  of  medical  service 
needed  is  important  in  determining  whether  or  not  a  patient  is  worthy 
•of  dispensary  treatment.  One  may  be  well  able  to  pay  a  general 
practitioner  for  treatment  of  a  minor  ailment  or  one  of  short  duration, 
but  unable  to  pay  for  a  specialist's  service  if  needed  or  for  treatment 
continuing  through  a  long  period  of  time.  On  the  basis  of  type  of  service 
needed  these  78  families  divide  into  55  whose  condition  of  illness  indi- 
cated the  need  of  specialist  service  and  23  who  presumably  could  have 
obtained  all  needed  service  from  a  general  practitioner.  From  this 
analysis  we  may  conclude  that  23  families  out  of  a  total  of  511',  or  4.5 
per  cent,  were  recipients  of  medical  charity  which  their  economic  status 
did  not  justify.  This  figure  closely  approximates  the  findings  of  the 
investigations  in  Boston,  New  York  and  St.  Louis  mentioned  above. 

The  pnblic  health  dispensaries,  for  example  those  conducted  by 
infant  welfare  organizations  and  by  public  or  private  agencies  for  the 
treatment   of  tuberculosis,   usually   treat   all   who   apply   regardless   of 

"  Here  are  included  only  those  families  for  whom  complete  income  statements 
could  be  obtained. 


94 


financial  ability.  If  pay  clinics  are  established  and  with  them  a  system 
of  compensating  dispensary  physicians  for  their  services,  the  question 
of  dispensary  abuse  will  tend  to  disappear. 

Efficient  dispensary  service  is  dependent  in  part  upon  competent  J 
management.  If  those  who  control  a  dispensary's  policies  and  direct 
its  activities,  realize  the  significance  of  the  work  the  institution  can 
perform  and  plan  to  make  that  work  commensurate  with  public  health 
needs,  such  an  institution  will  be  an  important  part  of  the  community's 
medical  facilities.  If  there  is  not  management  of  this  type,  and  too 
frequently  there  is  not,  a  dispensary's  value  may  be  very  limited.  From 
the  standpoint  of  the  community  the  value  of  a  dispensary  depends  upon 
the  type  and  quality  of'  its  medical  service,  upon  the  contribution  it 
makes  to  the  health  and  physical  wellbeing  of  the  people  it  serves.  Its 
relation  to  medical  school,  church,  social  settlement  or  other  organization 
is  significant  only  in  relation  to  this  primary  function. 

Unfavorable  social  conditions  may  cause,  accompany,  or  result  from 
sickness.  Efficient  medical  service  must  frequently  include  diagnosis 
and  treatment  of  attendant  social  conditions  as  well  as  of  the  disease 
from  which  the  patient  suffers.  Recognition  of  this  fact  has  led  to  the 
establishment  of  social  service  departments  in  many  of  the  better  dis- 
pensaries and  hospitals.  Such  a  department  aims  to  supplement  the 
work  of  the  doctor  by  giving  attention  to  various  elements  in  a  patient's 
environment  which  need  correction,  to  problems  in  the  solution  of  which 
he  needs  help,  if  the  doctor's  work  is  to  be  curative  rather  than  palliative. 
Social  service  is  making  valuable  contributions  to  dispensary  efficiency 
by  lengthening  the  period  during  which  patients  remain  under  treatment, 
by  correcting  home,  employment  and  other  conditions  intimately  related 
to  a  patient's,  illness  and  by  correlating  the  work  of  the  dispensary  with 
that  of  other  agencies  for  community  betterment.  A  more  detailed 
study  of  dispensary  social  service  will  be  found  in  Part  II. 

As  stated  above,  there  seems  to  be  developing  a  tendency  to  extend 
the  work  of  the  dispensary  beyond  the  group  who  seek  its  service  as  a 
charity,  to  people  of  low  or  moderate  income.  To  the  public  this  means 
a  more  extensive  utilization  of  the  medical  skill,  equipment  and  organi- 
zation found  in  the  dispensary.  It  means  pay  clinics ;  adequate  medical 
service  within  the  means  of  a  larger  part  of  our  population.  From  the 
standpoint  of  the  physician  it  is*  another  step  in  the  development  of' 
group  medicine  or  organized,  institutional  medical  practice. 

(4)   Nursing  Care. 

Trained  nursing  service,  while  in  more  or  less  universal  demand, 
is  of  very  recent  development.  The  first  training  school  for  nurses 
dates  back  only  to  1860  when  the  Nightingale  School  of  Nursing  was 
established  at  St.  Thomas'  Hospital,  London.  In  less  than  sixty  years, 
skilled  nursing  care  given  by  trained  people,  has  not  only  come  to  be 
regarded  as  an  essential  part  of  the  care  and  treatment  of  sick  people, 
but  it  has  also  become  more  specialized  and  exacting  as  the  prevention 
as  well  as  the  care  of  illness  has  become  better  understood.  Though 
the  degree  of  specialization  is  not  shown  by  it,  nursing  may  be  divided 
into  four  general  types,  viz.  the  institutional,  the  dispensary,  private 


95 

duty  or  resident  nursing,  and  public  health  nursing  (better  known  as 
visiting  or  district  nursing). 

Institutional  nursing  is  given  in  such  institutions  as  hospitals, 
convalescent  homes,  and  hospitals  for  the  insane.  It  is  done  by  student 
nurses  in  training,  by  attendants,  nursery  maids,  graduate  nurses  on 
ward  or  private  room  duty,  and  special  nurses,  and  is  generally  super- 
vised by  a  graduate  nurse  as  chief  executive  of  the  training  school  main- 
tained by  the  larger  hospitals.  The  special  nurse  devotes  her  full  time 
to  the  care  of  one  patient.  The  number  of  patients  assigned  to  each  of 
the  other  nurses  varies  according  to  her  degree  of  training  and  to  the 
ability  of  the  institution  to  provide  adequate  care  for  its  patients.  In 
some  institutions  too  many  patients  are  assigned  to  one  nurse. 

Dispensary  nursing  may  be  done  in  the  out-patient  department  of 
a  large  hospital,  in  general  or  special  dispensaries,  in  school  clinics,  and 
in  the  dispensaries  or  medical  departments  of  industrial  establishments. 
This  usually  consists  of  surgical  dressings,  certain  technical  treatments, 
and  the  supervision  of  and  assistance  in  special  clinics — i.  e.,  tubercu- 
losis, psychopathic,  for  children,  etc. 

Private  duty  or  resident  nursing  is  done  by  trained  nurses,  at- 
tendants, and  handy- women.  Ordinarily  the  nurse  spends  her  entire 
time,  from  twelve  to  twenty-four  hours  daily,  in  one  home,  giving  care 
to  one  or  more  patients.  There  is,  however,  some  ^'hourly  nursing" 
where  the  nurse  spends  one  or  more  hours  in  the  home  at  the  entire 
expense  of  the  patient. 

Public  health  nursing  is  provided  by  health  departments,  school 
departments,  tuberculosis  associations,  visiting  nurse  associations,  and 
infant  welfare  societies.  The  nurse  goes  into  the  home  to  give  such 
nursing  care,  instruction  and  oversight  as  the  condition  of  the  patient 
may  indicate  or  time  permit,  and  to  instruct  the  family  in  the  care  of 
the  patient  between  visits.  "Public  health  nursing'^  is  largely  a  new 
name  for  old  work.  It  covers  all  forms  of  home  visiting  both  for  the 
care  of  the  sick  and  by  instruction  and  demonstration  for  the  prevention 
of  illness.  Visiting  nursing,  school,  tuberculosis,  infant  welfare,  mental 
hygiene,  and  some  other  forms,  are  all  covered  by  the  term  "public  health 
nursing.'^ 

The  time  spent  in  each  home  by  a  public  health  nurse  depends  both 
upon  the  needs  of  her  patients  and  the  number  of  patients  under  her 
charge.  A  seriously  ill  patient  or  a  large  surgical  dressing  may  require 
a  daily  or  twice-daily  visit.  The  instruction  and  supervision  of  a  family 
in  which  there  is  pulmonary  tuberculosis  may  indicate  frequent  visiting 
but  the  number  of  cases  under  supervision  may  not  allow  more  than 
one  visit  a  fortnight.  The  home  instruction  of  a  young  mother  in  the 
modification  of  an  infantas  feedings  will  require  daily  visits  at  first,  later 
possibly  not  more  than  two  or  three  visits  a  month. 

Public  health  nursing,  from  small  beginnings  in  this  country  forty 
years  ago,  has  become  a  recognized  community  need.  District  nursing 
was  originally  only  the  care  of  the  sick  patient  in  his  home.  Later  it 
was  recognized  that  prevention  of  illness  by  trying  to  keep  the  other 
members  of  the  family  well,  was  quite  as  important  a  part  of  the  nurse's 


96 

work.  Experiments  in  the  home  care  of  tuberculous  patients  and  in  the 
home  supervision  of  school  children,  demonstrated  the  wisdom  of  having 
nurses  assigned  to  these  two  special  branches. 

Public  health  nursing  originated  as  a  charitable  effort.  The  initial 
step  in  all  of  this  work  has  been  undertaken  by  private  funds  and  as  its 
value  has  been  demonstrated  various  features  have  been  assumed  by 
public  funds.  *In  Illinois,  school  and  tuberculosis  nursing,  when  found, 
are  usually  supported  from  the  public  treasury.  In  Los  Angeles,  all 
visiting  nursing  to  the  destitute  poor  (tuberculosis,  child  welfare, 
maternity,  etc.)  is  provided  by  the  Health  Department.  In  Akron,  Ohio, 
there  is  a  Bureau  of  Public  Health  Nursing  in  the  Department  of  Health. 
In  Dayton,  Ohio,  all  home  service  is  given  by  a  staff  of  nurses  supported 
and  supervised  by  funds  from  the  Visiting  Xurse  Association,  the 
Health  Department,  and  the  Tuberculosis  League.  The  state  health 
departments  of  N'ew  York,  Minnesota,  Kansas  and  Ohio  have  state 
supervising  nurses  who  keep  closely  in  touch  mth  the  public  health 
nursing  work  in  counties  and  small  towTis. 

In  many  large  cities  this  service  is  given  to  the  poor  or  small  wage- 
earner  but  in  some  cities  a  privately  supported  Visiting  Xurse  Association 
combines  hourly  nursing  with  free  nursing.  Providence,  R.  I. ;  Cleve- 
land, Ohio;  Richmond,  Va. ;  Hartford  and  Xew  Haven,  Conn.;  and 
other  cities  have  demonstrated  that  these  two  types  of  service  can  be 
given  by  one  organization. 

A  census  of  nurses  taken  in  Illinois  in  February,  1918,  showed  that 
8,150  were  engaged  in  the  practice  of  nursing  for  hire  or  in  nurse-train- 
mg  schools.  Of  these  2,628  were  graduate  nurses,  3,639  were  student 
nurses,  and  1,899  were  attendants  and  orderlies.  This  enrollment  is 
incomplete  for  it  was  made  from  questionnaires  sent  out.  There  are 
doubtless  several  hundred  more  attendants  or  practical  nurses  in  the 
State.  Until  some  method  is  devised  for  the  registering  or  licensing 
of  all  people  who  practice  nursing,  any  census  must  necessarily  be 
mcomplete. 

A  gi'aduate  nurse  is  one  who  has  a  course  in  theoretical  and  practical 
nursing  in  a  school  attached  to  a  general  hospital.  The  1913  state  law 
for  the  registration  of  nurses  recognizes  only  those  schools  which  give  a 
three  year  course  and  meet  certain  standards  for  both  class-room  and 
hospital  work.  There  are  120  training  schools  in  the  State,  but  not  all 
i)f  these  are  on  the  accredited  list. 

A  practical  nurse  may  gain  her  knowledge  of  nursing  in  any  of 
several  ways.  She  may  have  some  hospital  training,  she  may  have 
taken  one  of  the  many  courses  in  nursing  offered  by  correspondence 
schools,  or  she  may  have  had  practical  experience  in  the  sick  room  at 
home.  As  a  rule,  such  nurses  have  little  or  no  systematic  theoretical 
instruction. 

Of  the  2,622  graduate  nurses  listed  in  Illinois,  about  500  are  doing 
public  health  nursing — about  400  in  the  City  of  Chicago  and  100  or 
more  elsewhere  in  the  State.  The  number  of  nurses  thus  employed 
varies  so  constantly  that  an  accurate  figure  is  next  to  impossible  to 


97 

obtain/^  Some  1,432  graduate  nurses  are  employed  in  various  institu- 
tions throughout  the  State.  Accordingly,  when  the  census  referred  to 
above  was  made,  there  were  not  more  than  700  graduate  nurses  left  for 
private  duty.  Nearly  1,000  graduate  nurses  from  Illinois  had  gone  into 
active  war  service,  but  even  before  their  departure  the  number  of  graduate 
nurses  for  private  duty  was  wholly  inadequate  to  meet  the  demand.  The 
number  is  always  smaller  than  of  those  professionally  trained,  for  many 
graduates  marry  and  give  up  nursing;  a  large  number  take  up  other 
work.  It  is  significant  that  private  duty  nursing  is  followed  by  such  a 
comparatively  small  number  of  graduates  when,  in  the  minds  of  the 
public,  hospitals  train  nurses  for  this  one  field. 

Trained  nurses  engaged  in  the  different  branches  of  nursing  out- 
side of  hospitals  are  very  unevenly  distributed  in  different  parts  of  the 
State.  Private  duty  nurses  are  available  or  may  be  secured,  though  in  in- 
adequate numbers,  in  all  of  the  larger  cities.  In  many  of  the  smaller 
places,  and  especially  in  many  of  the  mining  centers,  however,  they  are 
not  available.  Use  is  made  of  practical  nurses  or  "handy-women"  or 
no  nursing  service  is  had.^* 

The  same  deficiency  in  visiting  and  school  nursing  is  found  out- 
side of  Chicago.  Moline,  Peoria,  Springfield  and  a  few  other  places  have 
a  small  number  engaged  in  general,  school,  tuberculosis  and  infant  wel- 
fare nursing,  but  most  of  the  larger  places  have  an  inadequate  number, 
if  any,  while  rarely  do  the  smaller  places  have  any  at  all.  In  fact,  only 
about  fifty  places  outside  of  Chicago  have  public  health  nursing  by 
trained  people,  and  as  already  stated,  the  total  so  engaged  is  only  slightly 
in  excess  of  100.^^ 

School  nursing,  infant  welfare  work,  and  tuberculosis  nursing  have 
been  discussed  in  an  earlier  part  of  this  report.^^  At  this  point  it  is  only 
necessary  to  state  the  terms  on  which  nursing  may  be  had  in  hospitals 
and  private  homes  and  to  say  something  with  reference  to  the  non-special- 
ized visiting  nursing. 

The  hospitals,  of  course,  provide  general  nursing  service  for  their 
patients.  The  charge  for  a  special  nurse  is,  however,  borne  by  the 
patient.     The  cost  varies  somewhat,  but  the  usual  fee  for  a  graduate 

"In  the  summer  of  1917.  according  to  Illinois  Health  News,  September,  1917, 
pp.  228-231.  there  were  406  Public  Health  Nurses  in  Chicago,  and  102  outside  of 
Chicago.  Those  outside  of  Chicago  were  located  in  50  cities,  with  from  one  (In 
28  cases)  to  nine  (in  one  case)  each.  Of  those  outside  of  Chicago,  53  were  gen- 
eral nurses.  31  school  nurses,  11  tuberculosis  nurses,  5  industrial  nurses,  and  1  an 
infant  welfare  nurse.      Those  in   Chicago  were   distributed  as  follows  : 

Visiting    Nurse    Association 90 

Municipal   Tuberculosis  Nurses 75 

Infant  Welfare   Nurses 33 

Public    School    Nurses 149 

Hospital   Social   Service 17 

Industrial   Nurses    42 

Total   • 406 

"See  Hayhurst,  Health  Conditions  of  Coal  Miners,  Part  II  of  this  report, 
Special   Report  V.  .«,.,,, 

"See  preceding  chapter  and  Part  II  of  this  report.  Special  Report  XIII. 
18  See  Chapter  II  above. 


— 7  H  I 


98 


nurse  is  $30  per  week  in  general  cases,  and  $35  in  obstetrical  and  in- 
fections disease  cases.  Nurses  in  training  may  also  be  assigned  to 
"special  duty,"  in  which  case  the  fee  is  somewhat  smaller.  The  hospital 
charges  in  addition  from  $6  to  $10  per  week  for  the  special  nurse's  board. 

The  fee  of  the  resident  nurse  in  the  home  is  from  $30  to  $35  per 
week  for  the  graduate  nurse,  from  $15  per  week  upward  for  the  practical 
nurse.  The  fees  for  graduate  nurses  are  usually  established  by  the 
registry  or  nursing  organization  to  which  they  belong.  There  is  no 
fixed  fee  for  home  nursing  service  by  attendants.  The  fees  of  hourly 
nurses  are,  as  a  rule,  $2  for  the  first  hour  and  $1  for  each  succeeding  hour. 

The  service  of  the  visiting  nurse  is  given  free  to  all  persons  unable 
to  pay,  at  cost  to  patients  able  to  pay  this  sum  (from  50  cents  to  65 
cents),  at  some  other  figure,  say  25  cents,  where  the  patient  is  able  to 
pay  something  but  not  the  full  cost  of  the  service.  The  Metropolitan 
Life  Insurance  Company  provides  free  visiting  nursing  service  for  mosfc 
(about  90  per  cent)  of  its  industrial  policyholders,  and  certain  large 
individual  concerns  provide  it  for  their  employees. 

Considering  the  long  hours,  the  broken  rest,  the  period  of  training 
required  to  become  a  graduate  nurse,  and  the  responsibility  which  good 
nursing  entails,  the  maintenance  of  a  home  or  lodgings,  and  the  time 
"off"  required  for  rest  between  cases,  the  fees  for  private  duty  nursing 
are  not  excessive.^^  The  earnings  of  nurses  are  not  continuous  for  the 
year  at  the  weekly  rate.  As  will  be  shown  later,  in  certain  seasons  of  the 
year  there  is  very  little  call  for  private  duty  nursing.^^  Yet  it  must  be 
said  that  the  cost  is  prohibitive  for  most  families. ^^  Hence  the  develop- 
ment of  visiting  nursing  which  has  taken  place. 

General  visiting  nursing  in  Illinois  has  been  developed  only  to  a 
limited  extent  outside  of  Chicago.  Because  of  this  fact  use  may  be  made 
of  the  Visiting  T^urse  Association  in  Chicago  to  indicate  more  concretely 
the  nature  of  the  service  and  its  possibilities. 

In  1917,  the  Visiting  Xurse  Association  of  Chicago  made  241,352 
home  visits  to  34,427  patients,  at  a  cost  of  55  cents  per  visit,  giving  an 
average  of  7  visits  to  each  patient.  Some  patients  received  more  than 
100  visits,  others  were  dismissed  on  the  first  visit.  This  work  was  done 
at  an  expense  to  the  Association  of  $134,346.  Seventy-one  per  cent 
was  free  w^ork,  not  paid  for  by  patient,  employer  or  insurance  company. 
About  50  per  cent  were  known  to  other  public  or  philanthropic  a.ijencies, 
although  many  were  not  registered  with  societies  giving  material  relief. 
Some  were  known  only  to  dispensaries,'  hospitals,  courts,  social  settle- 

"  In  return  for  instruction  and  maintenance,  the  student  nurse  usuaUy  gives 
her  time  and  strength  for  three  years  to  the  hospital  in  which  she  is  receiving 
her  training.  The  cost  of  the  training  is  covered  by  the  work  done  in  the  insti- 
tution, and  is  considered  comparable  to  a  technical  training,  where  the  student 
bears  not  only  all  of  her  personal  expenses,  but  in  addition,  pays  tuition  or  fees 
for  an  academic  course  embracing  class-room  and  laboratory  work.  The  student 
in  a  hospital  is,  however,  on  active  duty  from  56  to  70  hours  per  week  for  50 
weeks  in  the  year.  The  time  spent  in  the  class-room  averages,  as  a  rule,  not 
more  than   from   100   to   150   hours   per  year. 

^^  See  p.   101. 

"  In  addition  to  the  fee  to  be  paid,  there  is  the  problem  of  providing  for  an 
additional  member  of  the  family. 


99 

ments,  etc.  Less  than  25  per  cent  of  the  whole  group  were  receiving 
free  medical  service  from  the  County  physicians.  Twenty-one  per  cent 
of  the  group  needed  assistance  from  no  outside  agency  other  than  the 
Visiting  Xurse  Association.  Approximate  1}'  15  per  cent  of  these  calls 
came  from  families  known  to  the  Association  in  previous  years. 

This  very  large  amount  of  free  work — 71  per  cent — shows  the  need 
of  this  nursing  service  in  homes  where  illness  suddenly  breaks  into  the 
regular  routine.  An  extension  of  this  service  to  all  families,  not  merely 
to  the  homes  of  the  small  wage-earners,  is  desirable.  A  study  made 
June  20,  1917,  of  653  Chicago  families  entered  by  the  visiting  nurses 
showed  that  less  than  25  per  cent  of  these  families  had  a  weekly  income 
of  $20  or  more.  Free  service  was  given  in  316  homes  or  just  about  one 
half.  In  the  remaining  homes,  something,  from  a  small  fraction  of  the 
cost  to  the  full  cost,  was  paid  for  the  service.  A  similar  study  made  by 
the  Instructive  District  ISI^ursing  Association  of  Boston  showed  that  only 
13  per  cent  of  the  1,038  families  investigated  had  a  weekly  income  of 
$20  or  more. 

The  question  is  frequently  asked  if  many  of  these  calls  are  not  sent 
in  unnecessarily,  especially  when  public  health  nursing  is  supported  by 
public  funds.  A  careful  analysis  of  the  cases  dismissed  on  first  visit  in 
1916  showed  that  although  14  per  cent  of  the  patients  of  the  Visiting 
Xurse  Association  were  thus  dismissed,  approximately  10  per  cent  were 
dismissed  to  hospitals  and  to  other  agencies;  a  few  had  sent  in  wrong 
addresses.  Xot  more  than  4  per  cent  came  from  homes  where  there  was 
no  illness,  and  even  in  these  homes,  it  was  possible  to  explain  the  service 
and  not  infrequently  to  give  some  much  needed  advice  regarding  the 
care  of  a  convalescent  or  a  little  child. 

The  experience  of  the  insurance  companies  is  much  the  same. 
About  6  per  cent  of  the  calls  received  from  the  Metropolitan  Life  In- 
surance nursing  service  in  Chicago  in  1917,  was  dismissed  on  the  first 
visit.  In  only  1  per  cent  of  these  calls  was  there  no  illness.  The  re- 
maining 5  per  cent  were  transferred  to  the  general  visiting  nurse  service 
because  the  patients  were  not  insured  or  had  no  physician  in  attendance 
and  hence  Avere  not  entitled  to  tlie  Metropolitan  service. 

All  good  public  health  nursing  is  done  in  close  cooperation  with 
local  physicians,  but  it  is  sometimes  necessary  to  keep  a  patient  under 
supervision  for  days  before  the  family  will  consent  to  the  expense  of 
calling  a  physician.  These  patients  are  not  given  treatment,  they  are 
simply  watched  and  advised.  Medical  service  is  frequently  obtained 
for  patients  distinctly  in  need  of  it,  because  the  need  has  first  been  dis- 
covered by  a  public  health  nurse,  and  the  family  watched  until  it 
recognizes  the  value  of  immediate  medical  service.  Most  visiting  nurse 
patients  are  like  other  human  beings,  and  send  for  a  doctor  promptly  if 
acute  symptoms  precede  a  slight  or  serious  attack  of  illness,  but  incipent 
and  less  tangible  symptoms  of  serious  physical  disability  are  frequently 
overlooked  until  the  doctor  is  called  too  late. 


100 


^^  In  view  of  the  extensive  interest  at  present  displayed  in  the  in- 
adequate nursing  service  in  the  State,  something  should  be  said  with 
reference  to  what  adequate  trained  service  would  require.  The  only 
carefully  worked  out  estimate  seems  to  be  one  derived  from  a  survey  of 
five  districts  in  Dutchess  County,  New  York,  made  in  1912.  In  a  total 
population  of  11,800  living  under  fairly  typical  urban  and  rural  con- 
ditions, 1,600  cases  of  serious  illness  were  studied.  Nine  thousand 
working  days  were  lost  by  men  and  women;  13,700  school  days  were  lost 
by  children.  Chronic  invalidism  caused  31  per  cent  of  the  cases  studied. 
The  general  results  may  be  quoted  from  the  report  and  the  conclusions 
arrived  at  stated. ^° 

"In  this  report  the  term  'sickness'  is  limited  for  our  purpose  to  that 
which  was  so  ssrious  that  it  either  necessitated  or  should  have  necessitated 
the  patient's  going  to  bed  or  securing  medical  aid.  A  slight  ailment,  such 
as  indigestion,  head-ache,  or  a  light  cold,  was  not  taken  into  account." 

"By  'adequate  service'  is  meant  that  service  which  insures  the  patient's 
rscovery  when  recovery  can  be  expected,  and  which  is  of  such  a  character 
that  neither  the  patient  nor  the  community  incurs  avoidable  risks." 

"Seventy-two  per  cent  of  all  the  cases  studied  could  have  been  cared  for 
adequately  in  their  own  homss,  had  there  been  available  nursing  service." 
"Twenty-four  per  cent  of  the  patients  secured  no  medical  cars."  "Much  of 
the  sickness  recorded  was  due  to  lack  of  early  and  accurate  diagnosis." 
"There  is  no  attempt  in  the  county,  by  organization,  to  make  sura  that  those 
who  most  needed  the  services  of  trained  nurses,  secured  them,  or  to  insure 
a  sufficient  supply  of  trained  household  attendants  and  domestic  servants, 
though  this  type  of  service  made  up  60  per  cent  of  the  help  needed  in  homes 
where  there  was  sickness." 

"Of  the  113  women  who  went  through  child-birch  in  their  homes,  only 
one  had  the  continuous  care  of  a  graduate  nurse,  and  only  18  had  any  service 
whatsoever  from  graduate  visiting  nurses.  Thirty-five  per  cent  of  the  chil- 
dren born  came  into  the  world  under  unfit  conditions  and  surroundings." 

"Of  the  total,  1,441  patients,  90  per  cent  remained  in  their  homes  during 
their  entire  illness.  Of  these,  2  per  cent  secured  resident  trained  nursing 
service;  4  per  cent  secured  visiting  trained  nursing  service;  5  per  cent 
were  cared  for  by  a  resident  untrained  nurse;  less  than  1  per  cent  by  a 
visiting  untrained  nurse.  In  2  per  cent  of  the  homes,  resident  domestic 
help  was  secured,  and  in  one  home,  visiting  domestic  help  was  secured.  In 
59  per  cent  some  member  of  the  family  did  whatever  nursing  was  done." 

"Of  the  trained  nursing  service  secured,  42  per  cent  was  resident  and 
58  per  cent  visiting.  Of  the  untrained  service,  not  including  nursing  by 
members  of  the  family,  72  per  cent  was  resident  and  28  per  cen:  visiting. 
Of  the  total  service  received,  22  per  cent  of  the  resident  service  was  trained, 
v8  per  cent  untrained;  of  the  visiting  service,  56  per  cent  was  trained  and 
44  per  cent  untrained." 

As  a  result  of  this  survey,  the  Committee  reached  the  following 
conclusions:  The  number  of  days  of  resident  graduate  nursing  service 
would  keep  an  average  of  14  nurses  employed,  varying  from  9  to  27  per 
month,  an  average  of  one  resident  graduate  nurse  to  every  840  of  the 
population.  Eighty-eight  per  cent  of  the  families  requiring  this  service 
were  able  to  meet  the  full  expense.  Allowing  one  visiting  nurse  to  every 
2,500  population  and  one  school  nurse  to  every  1,600  population,   35 

20  Sickness  in  Dutchess   County,  New    York,  a   report  made   by   the   Committep 
on   Hospitals   of  the   State   Charities  Aid  Association   and  published  in   New   York 


101 

public  health  nurses  would  be  needed  to  care  for  the  entire  community. 
Estimating  one  resident  trained  attendant  for  every  1,200  people  would 
necessitate  the  constant  employment  of  75  attendants.  Kesident  do- 
mestic help  was  needed  in  many  homes  on  account  of  the  illness  of  the 
housekeeper,  and  108  women  would  be  required  to  nieet  the  need  of  a 
service  of  this  sort.  The  estimate  of  one  visiting  nurse  to  every  2,500 
population  was  made  for  rural  and  urban  communities;  one  nurse,  in 
urban  conditions,  could  undoubtedly  meet  the  needs  of  every  5,000 
population.  Students  of  the  work  of  school  nurses  recommend  one  nurse 
for  every  3,000  or  4,000  school  children  in  congested  quarters. 

Using  the  estimate  made  in  this  report,  Illinois  would  require  not 
less  than  5,000  private  duty  nurses,  2,000  public  health  nurses,  4,000 
domestic  helpers  for  the  care  of  the  sick  in  their  own  homes.  It  is 
necessary  to  consider  the  use  of  domestic  helpers,  servants,  or  "handy- 
women'^  as  they  are  variously  called,  in  an  estimate  of  this  sort  for  in 
many  homes  the  illness  of  the  mother  or  the  caretaker  makes  household 
service  of  this  type  absolutely  essential. 

The  Dutchess  County  experience  showed  that  while  the  number  of 
public  health  nurses  required  would  be  fairly  constant,  as  the  instructivG 
work  was  considered  equally  important  with  the  bedside  care,  the  number 
of  nurses  for  resident  private  duty  varied  from  9  to  27,  giving  an  average 
of  14.  In  other  words,  in  certain  seasons  of  the  year  three  times  as  many 
resident  nurses  would  be  required.  In  Chicago,  the  average  private 
duty  nurse  is  busy  seven  months  of  the  year.  The  late  spring,  summer 
and  fall  months  usually  require  one-third  as  many  resident  special  nurses 
as  are  in  demand  during  the  winter  and  spring.  A  nursing  registry 
enrolling  600  graduate  and  attendant  nurses  reports  that  while  it  can 
rarely,  if  ever,  meet  the  demands  made  upon  it  in  February,  in  June  it 
has  had  as  many  as  160  idle  nurses  on  its  waiting  list.  It  further  reports 
that  an  equal  number  had  gone  home  or  taken  up  other  work. 

This  condition  does  not,  of  course,  apply  to  epidemic  years.  It 
would  be  impossible  to  meet  the  tremendous  demands  made  upon  that 
nursing  service  during  an  epidemic  like  influenza  in  1918  or  scarlet 
fever  in  1913.  Epidemiologists  have  charted  the  expectancy  of  recur- 
rent epidemics  of  pneumonia,  scarlet  fever  and  diphtheria  with  a  start- 
ling accuracy. 

To  meet  the  nursing  need  of  any  given  population  in  periods  of 
slight  or  of  acute  illness,  two  plans  suggest  themselves:  First,  that 
resident  graduate  nurses  be  used  in  all  households  during  the  period  of 
critical  illness,  the  expense  to  be  borne  in  part  by  the  family  and  in  part 
by  public  funds,  if  proper  investigation  has  shown  that  the  expense  is 
beyond  the  family's  means.  Public  health  nurses  may  be  sent  in  daily 
after  the  resident  nurse  has  been  dismissed,  to  give  such  care  as  the 
patient  requires,  this  care  to  be  supplemented  by  members  of  the  family. 
Second,  that  courses  in  home  nursing  be  made  compulsory  for  all  girls 
in  eighth  grades  and  in  the  first  year  of  the  high  school,  so  that  in  time 
all  women  will  have  at  least  a  working  knowledge  of  personal  hygiene, 


102 


home  sanitation  and  household  nursing.  A  six  or  a  twelve  months* 
course  in  nursing  rather  than  the  present  three  years'  course  may  also 
be  a  solution  of  the  inadequate  supply  of  nursing  service  in  the  homes, 
but  it  remains  to  be  seen  if  women  in  sufficiently  large  numbers  will  take 
these  courses. 

If  resident  skilled  nursing  may  be  dispensed  with,  but  a  better  kind 
of  supplementary  nursing  than  the  average  household  can  give  is  neces- 
sary, this  may  be  furnished  by  attendants.  The  price  paid  for  this 
service  must  make  a  living  and  desirable  wage  for  the  individual  earning 
it.  An  appeal  to  the  women  of  a  community  to  take  special  training 
in  order  that  they  may  give  this  service  to  their  communities  at  the  price 
the  community  is  able  to  pay,  will  attract  few  candidates  because  in 
less  ardous  work  the  same  amount  or  more  money  is  more  easily  earned.  ■ 
This  fact  must  not  be  overlooked  in  deciding  upon  any  plan  of  commun- 
ity nursing. 

Public  hospitals,  dispensaries  and  free  medical  service  are  pro- 
vided for  people  unable  to  employ  physicians.  It  is  a  well  recognized  fact 
that  the  best  physician  is  not  too  good  for  the  working-man  because  the 
poor  man  can  least  of  all  afford  to  be  ill.  Consequently  in  planning 
nursing  care  for  the  sick  poor  or  the  sick  of  the  middle  class,  we  must 
look  upon  it  firsts  from  the  standpoint  of  the  needs  of  the  patient  for 
skilled  or  unskilled  nursing  care;  second,  from  the  ability  of  women  in 
that  community  to  work  for  the  wages  offered ;  third  and  least  important, 
from  the  standpoint  of  cost. 

Better  organization  of  the  nursing  resources  of  any  community  will 
in ,  time  help  solve  this  problem.  Three  plans  have  been  suggested. 
First,  the  Brattleboro  plan  has  been  tried  and  has  proved  successful  for 
a  small  community.  Second,  the  Cincinnati  Unit  plan  has  been  in 
effect  about  one  year  but  its  results  are  already  very  promising.  Third, 
the  Dutchess  County  plan  has  been  recommended.  It  is  really  a  com- 
bination of  both  the  Brattleboro  and  the  Cincinnati  plan  but  has  not  as 
yet  been  tried  out'  on  a  sufficiently  large  scale  to  make  workable  deductions 
possible. 

In  Brattleboro  an  association  providing  community  home  nursing, 
attempts  to  suppl}^,  first,  the  services  of  a  graduate  nurse  during  the  most 
critical  state  of  the  illness;  second,  an  attendant  nurse  for  convalescent 
and  chronic  patients;  third,  domestic  help  by  the  day  or  hour  in  homes 
where  this  is  needed.  This  sort  of  organization  is  more  successful  in 
small  communities  than  in  large  because  there  are  fewer  opportunities 
for  M^omen  to  dispose  of  their  services  in  other  ways,  therefore  positions 
as  domestic  helpers  and  as  attendant  nurses  are  more  easily  filled. 

In  Cincinnati,  the  National  Social  Unit  Organization  plans  to 
organize  all  of  the  social  agencies  in  one  neighborhood — physicians, 
nurses,  relief  workers,  churches,  settlements,  schools,  and  the  citizens 
themselves — for  more  efficient  neighborhood  service  to  one  another.  This 
is  more  than  a  redistribution  of  the  nursing  facilities;  it  plans  the 
socialization  of  the  medical,  recreational,  educational  and  other  neighbor- 


i03 

hood  interests  and  is  attempting  to  introduce  small  town  neighborliness 
into  large  and  heterogeneous  communities. 

The  Dutchess  County  report  recommends  the  following  plan  of 
organization : 

OBJECT. 

"The  health  assocation  would  have  as  its  object  the  coordination  and 
development  of  existing  facilities  of  the  community  for  the  care  of  the  sick 
and  the  prevention  of  disease,  in  order  to  make  them  thoroughly  efficient  and 
readily  available  to  all,  and  the  development  of  such  additional  facilities  as 
study  and  experience  may  indicate  are  needed. 

"The  association,  however,  cannoi;  attain  these  objects  unless  it  has  the 
sympathetic  interest  and  cooperation  of  the  physicians  in  the  county.  Their 
interest  and  cooperation  must  underlie  all  its  work  and  are  vitally  essential 
to  its  success. 

MAIN   LINES   OF  WORK. 

"In  order  to  do  itS  work  most  efficiently,  the  association  should  cooperate 
with  all  the  public  and  private  medical  and  social  service  agencies  at  work 
in  the  county,  along  the  following  lines: 

A.    REMEDIAL.   WORK. 

1.  Establishing  an  efficient  system  of  medical,  nursing  and  social  service 
for  the  care  of  the  sick  in  their  own  homes. 

2.  Securing  the  cooperation  of  the  existing  hospitals,  stimulating  the 
provision  of  additional  facilities  where  and  when  clearly  needed. 

3.  Maintaining  a  proper  distribution  of  patients  as  between  home  and 
hospital  care,  based  on  a  study  both  of  the  patient's  disease  and  of  his 
social  and  economic  circumstances. 

B.    PREVENTIVE   WORK. 

1.  Educating  the  individual:  (a)  as  to  personal  hygiene  and  the  obser- 
vation of  its  law;  (b)  as  to  the  nature  of  communicable  diseases  and  the 
means  of  avoiding  them  as  well  as  the  necessity  of  collective  action  to  safe- 
guard health  and  avert  danger  from  these  sources;  and  (c)  as  to  the  bad 
housing  and  unfit  social  and  industrial  conditions  in  which  he  lives  and  the 
means  that  can  be  employed  to  improve  those  conditions. 

2.  Securing  the  adoption  and  strict  enforcement  of  public  health  meas- 
ures, i.  e.,  public  hygiene." 

For  several  years  the  Central  Branch  of  the  Young  Women's 
Christian  Association  of  New  York  City  has  conducted  an  eleven  weeks' 
course  for  trained  attendants  and  writes  as  follows: 

"The  trained  attendant  must  be  fairly  well  educated  for  she  must  take 
the  place  of  a  trained  nurse  and  is  often  relied  upon  for  companionship  and 
advice.  Therefore  we  require  an  entrance  examination  of  all  who  are  not 
high  school  graduates.  In  normal  times  we  graduate  about  150  each  year. 
During  the  war  period  we  graduated  about  300  annually.  These  graduates 
earn  from  $12  to  $18  per  week,  including  room  and  board,  and  are  constantly 
busy." 

Assuming  that  there  are  many  women  able  and  willing  to  take  a 
shorter  course  in  nursing  than  the  present  three  years'  training,  there 


104 


have  been  no  places  in  Illinois  where  this  training  was  offered.  It  is 
now  proposed  that  many  of  the  hospitals  which  are  conducting  second  and 
third  rate  training  schools  for  nurses,  discontinue  their  attempt  to 
train  three  year  nurses  and  institute  shorter  courses.  In  this  wav  a 
second  and  much  larger  gi'oup  of  women  with  nursing  experience  can  be 
developed  in  a  fairly  short  time. 


105 


CHAPTER  IV.     EXISTING  HEALTH  INSURANCE. 


(1)   Introduction. 

No  fewer  than  ten  European  countries  (Germany,  Austria,  Hun- 
gary, Luxembourg,  Norway,  Serbia,  Great  Britain,Eussia,  Roumania, 
and  the  Xetherlands)  have  made  health  insurance  compulsory  for  many 
or  most  wage-earners.^  So  have  some  of  the  Swiss  cantons,  and  in  1917 
a  Commission  was  created  in  Italv  to  draft  a  bill  for  enactment  into  law. 
Three  countries  (France,  Italy  and  Denmark)  have  for  some  time  had 
compulsory  insurance  of  workmen  in  a  few  occupations.  The  govern- 
ments of  Switzerland,  Belgium,  France,  Sweden  and  Denmark  have  a 
system  of  health  insurance  subsidies. 

Whatever  may  have  been  the  motives  leading  to  the  adoption  of 
compulsory  health  insurance  in  some  of  these  countries,  the  systems 
adopted  have  extended  insurance  to  many  wage-earners  theretofore  with- 
out it,  have  standardized  the  compensation  and  medical  benefits  provided 
and  made  obligatory  as  minima  a  level  of  benefits  previously  not  generally 
granted  by  the  various  insurance  institutions  which  had  grown  up. 
With  unimportant  exceptions  under  this  legislation  use  Avas  made  of 
existing  institutions  on  condition  that  they  met  certain  conditions  pre- 
scribed by  law;  then  new  organizations  were  created  or  old  ones  (e.  g. 
the  Post  Office  in  Great  Britain)  were  used  to  provide  carriers  for  work- 
men who  failed  to  secure  membership  in  institutions  of  the  type  already 
providing  sickness  benefits. 

It  is  unnecessary  to  present  the  history  of  this  European  legislation, 
to  outline  accurately  its  detail,  or  to  give  an  account  of  the  operations 
under  it.  Concise  accounts  of  the  two  leading  systems,  those  of  Germany 
and  Great  Britain,  will  be  found  in  Part  II  of  this  report.  A  table 
showing  the  dates  when  seven  of  tlie  systems  were  adopted,  the  main 
classes  now  insured,  the  main  benefits  prescribed,  and  the  division  of 
the  cost  must  suffice.  It  should  be  noted,  however,  that  under  this  legis- 
lation the  minimum  benefits  may  generally  be  extended  and  made  more 
liberal,  and  that  certain  classes  not  under  the  necessity  of  becoming 
insured,  may  become  voluntary  members  in  the  "funds.^' 

^  It  has  been  stated  that  Sweden  adopted  compulsory  health  Insurance  in  1918, 
but  careful  search  leads  to  the  conclusion  that  the  statement  is  incorrect. 


106 


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those     with     fewer     servants  not  in- 
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ployees  excepted. 

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108 

The  outstanding  facts  in  this  compulsory  insurance  legislation  are 
these:  (1)  the  application  of  the  principle  of  compulsion  to  extend 
insurance  to  many  persons  theretofore  not  insured;  (2)  the  prescription 
of  minimum  benefits — these  being  partial  compensation  of  wages  lost 
because  of  disabling  sickness,  medical  and  perhaps  hospital  treatment, 
maternity  care  or  payments,  and,  usually,  burial  allowances;  (3)  the 
option  given  the  mutual  carriers  of  increasing  the  benefits  over  the 
minima  prescribed;  (4)  a  prescribed  method  of  meeting  the  cost  so  as  to 
distribute  it  between  employers  and  workmen,  or  among  these  and  the 
state;  and  (5)  a  system  of  control  by  those  who  contribute  to  the  funds, 
with  state  supervision  through  governmental  machinery  set  up. 

These  are  the  outstanding  facts  as  shown  by  an  analysis  of  legis- 
lation. With  the  legislation  in  effect  other  significant  facts  are  revealed, 
for  compulsory  health  insurance  alters  the  practice  of  medicine  more  or 
less  extensively,  and  may  profoundly  change  the  relation  of  the  hospital 
and  other  medical  institutions  to  the  community.  It  may  also  have 
important  effects  on  labor  organizations  and  other  institutions.  Such 
matters  as  these,  however,  do  not  require  discussion  at  this  point,  for  a 
more  fitting  place  for  the  needed  discussion  is  found  in  the  next  chapter 
of  this  report. 

Our  investigations  show  that  a  great  manv  institutions  providing 
health  insurance  for  wage-earners  are  to  be  found  in  Illinois.  Among 
them  are  establishment  funds  maintained  by  employers,  or  by  their  em- 
ployees, or  by  employers  and  their  employees  jointl}^;  trade  unions; 
fraternal  societies;  "independent  foreign'^  societies;  "burial  societies;" 
and  insurance  companies  of  various  kinds.  Considered  collectively  the 
benefits  provided  by  them  include  almost  all  of  the  benefits  provided 
under  an  inclusive  health  insurance  system.  Yet  health  insurance 
as  now  found  in  Illinois  presents  a  striking  contrast  to  the  systems 
developed  in  the  leading  European  countries.  Except  for  the  disability 
allowances  permitted  under  the  pension  funds  for  public  employees," 
none  of  it  is  in  government  insurance  funds  or  subsidized  out  of  public 
monies,  and  only  the  smaller  part  of  it  is  regulated  or  supervised  by  the 
public  authorities.  While  the  principle  of  compulsion  is  applied  here 
and  there  by  employers  or  by  labor  organizations,  it  is  nowhere  applied 
by  the  State.  In  other  words,  the  existing  insurance  is  voluntary,  with 
or  without  pressure  exerted  by  private  parties.  If  cash  benefits  in  com- 
pensation for  lost  wages  are  considered,  our  investigations  show  (1)  that 
while  there  are  great  variations  between  races,  localities  and  industries, 
perhaps  only  about  thirty  per  cent  of  the  wage-earners  of  Illinois  as  a 
whole  have  such  insurance;  (2)  that  this  insurance  is  not  standardized 
so  that  frequently  the  compensation  is  in  relatively  small  sums,  most 
of  it  is  limited  to  comparatively  short  periods,  and  frequently  certain 
classes  of  wage-earners  or  certain  types  of  disease  are  excluded;'  (3)  that 
most  frequently  the  entire  cost  of  compensation  provided  is  met  by  the 
payments  of  the  insured;  (4)  that  in  some  cases  because  of  necessarily 
high  acquisition  costs  in  \j^riting  voluntary  insurance,  the  premiums 
greatly  exceed  the  total  returned  to  the  insured;  and  (5)  that  frequently 

^  For  an  account  of  this,  see  Report  of  Illinois  Commission  on  Pension  Laws. 


109 

the  interests  of  the  insured  are  not  safeguarded  by  the  system  of  admin- 
istration developed.  A  much  smaller  percentage  of  wage-earners  are 
entitled  to  medical  and  hospital  treatment  and  nursing  care  than  to  cash 
benefits  under  the  insurance  they  have.  Maternity  benefits  and  provision 
for  maternity  care  are  rarely  found.  The  majority  of  wage-earners  and 
a  large  majority  of  their  dependents  are,  however,  provided  with  "funeral 
benefits"  or  "burial  insurance"  or  life  insurance  in  small  or  moderate 
amounts.  As  in  other  commonwealths,  so  in  Illinois  this  is  the  one  phase 
of  "health  insurance"  that  has  been  highly  developed.  However,  some 
of  this  insurance  in  foreign  societies  and  fraternal  orders  is  not  entirely 
safe  because  of  inadequate  premiums  or  reserve  funds,  while  that  carried 
on  individual  policies  with  industrial  insurance  companies  is  relatively 
expensive  because  of  the  high  acquisition  costs  connected  with  the 
necessity  of  maintaining  a  large  number  of  agents. 

In  these  respects  existing  health  insurance  in  Illinois  stands  in  con- 
trast to  compulsory  health  insurance  as  developed  in  some  of  the 
European  countries.  Of  course  the  statements  here  made  are  not  in- 
tended to  argue  for  compulsory  health  insurance,  or,  for  that  matter,  for 
any  change  from  the  existing  situation.  They  are  intended  merely  to  set 
forth  facts.  Conclusions  with  reference  to  what  ought  to  be  and  the 
Commission's  recommendations  are  presented  in  the  next  chapter  of  this 
report. 

In  Part  II  of  this  report  the  results  of  the  staff's  investigations  of 
health  insurance  provided  by  ^establishment  funds, .  labor  organizations, 
national  and  "local  fraternal  organizations,  .independent  foreign  societies, 
ana  insurance  companies  of  different  kinds  are  set  out  in  some  detail. 
Those  who  wish  to  secure  a  comprehensive  statement  of  the  existing 
insurance  situation  must  consult  these  several  reports.^  At  this  point 
it  is  possible  only  to  bring  together  and  set  out  the  more  significant 
facts. 

(2)   Establishment  Funds. 

The  Commission's  investigations  have  shown  that  establishment 
funds  maintained  by  employers  alone,  by  their  employees  alone,  or  by  the 
two  jointly,  are  one  of  the  most  important  institutions  providing  benefits 
in  cases  of  sickness  and  death.  A  list  has  been  made  of  134  such  funds 
or  benefit  systems  in  operation  in  Illinois  and  115  of  these  have  been 
studied  in  some  detail.  Some  of  these  are  for  workmen  in  a  given  plant ; 
others  extend  to  the  workmen  employed  in  two  or  more  plants  operated 
by  a  given  firm.  The  be^t  estimate  it  has  been  possible  to  make  is  that 
not  less  than  150,000  and  not  more  than  200,000  wage-earners  are 
employed  in  Illinois  establishments  in  which  the  134  known  benefit 
systems  are  in  operation.  Thus  more  or  less  extensive  provision  has 
been  made  for  meeting  the  problem  here  dealt  with  in  the  plants  in  which 

8  Perhaps  it  should  be  stated  that  our  investigations  related  especially  to  in- 
surance against  disability  from  sickness  and  non-industrial  accidents  and  to  funeral 
benefits.  Only  because  life  insurance  as  distinguished  from  funeral  benefits  serves 
to  cover  the  expenses  of  the  last  illness  and  burial  costs  as  well  as  to  provide 
for  the  needs  of  dependents  has  it  come  within  the  scope  of  the  Commission's 
investigations.  For  this  reason  life  insurance  has  been  dealt  with  only  incidentally 
and  no  attempt  has  been  made  to  Investigate  or  to  discuss  the  organized  life  in- 
surance business  as  such. 


110 

from  7^2  to  10  per  cent  of  the  wage-earners  of  the  State  are  employed. 
Perhaps  65  per  cent  of  these  are  members  of  the  funds  maintained. 

The  extent  to  which  establishment  funds  have  been  organized  varies 
greatly  from  one  locality  or  industry  to  another.  In  respect  to  locality 
they  are  found  most  conspicuously  in  Chicago,  Moline,  and  East  St. 
Louis.  In  respect  to  industry  most  of  the  funds  are  found  in  the  iron 
and  steel  plants,  large  establishments  engaged  in  the  manufacture  of 
agricultural  implements,  the  meat-packing  plants,  and  the  large  stores 
of  Chicago,  or  are  operated  by  the  railroad,  telephone  and  other  utility 
companies.  They  find  practically  no  place  in  coal  mining  and  the  build- 
ing trades  where  the  men  are  well  organized  into  unions,  and  in  the  many 
industries  and  businesses  conducted  on  a  small  scale. 

The  establishment  fund  is  largely  the  product  of  experience  with 
the  emergencies  presented  by  disabling  sickness  and  death.  In  the 
absence  of  such  systematic  provision  for  paying  benefits,  employers  have 
frequently  paid  wages  to  the  more  valued  of  their  employees  and  have 
contributed  to  the  relief  of  others.  The  employees  themselves  have  fre- 
quently "passed  the  hat."  The  establishment  fund  has  been  developed 
to  meet  the  situation  in  a  more  svstematic,  more  certain,  and  more  satis- 
factory  way.  This  method  has  made  considerable  headway  during  the 
last  ten  years.  Yet  it  is  by  no  means  new.  AMiile  the  majority  of  the 
115  funds  studied  in  detail  were  found  to  have  been  organized  during 
the  last  eight  or  ten  years,  no  fewer  than  20  were  found  to  have  been  in 
operation  for  twenty  years  or  more,  and  the  oldest  had  been  in  continuous 
operation  since  1874.  jSTot  all  of  those  organized  have  brought  a  net 
gain,  however,  for  a  considerable  number  have  been  given  up  after  a 
longer  or  shorter  experience.  In  a  few  of  these  cases  this  has  been  due 
to  the  opposition  of  employees  who  have  been  organized  into  unions 
providing  benefits  and  who  then  objected  to  making  contributions  for  the 
support  of  two  benefit  systems.  In  other  cases  the  employer,  confronted 
by  union  demands,  has  changed  his  labor  policy  and  given  up  his  wel- 
fare plans.  Some  funds  were  discontinued  when  workmen's  compen- 
sation was  adopted  and  the  old  provision  for  cases  of  industrial  accident 
was  no  longer  needed.  Finally,  some  benefit  systems  have  been  dis- 
continued because  the  expected  gains  had  not  been  fully  realized  or  be- 
cause of  administrative  difficulties  which  had  arisen. 

Of  the  115  establishment  funds  studied,  22  are  organized  and  (with 
occasional  subsidies)  conducted  by  the  employees,  82  are  organized, 
conducted  and  supported  by  the  employers  and  their  employees  jointly, 
while  II  are  conducted  and  supported  entirely  by  the  employers.  Thus 
three  general  types  are  found.  It  should  be  pointed  out  in  this  con- 
nection, however,  that  in  59  of  the  82  funds  of  the  second  type,  the 
employers  contribute  only  by  bearing  the  incidental  cost  of  administra- 
tion (chiefly  collecting  the  dues)  and  now  and  then  making  grants  in 
aid  when  deficits  are  incurred.  The  evidence  is  rather  slight,  but  indi- 
cates a  tendency  towards  the  adoption  of  funds  organized,  conducted 
and  supported  by  the  employers.  This  appears  to  be  due  to  the  desire 
to  get  rid  of  administrative  difficulties  and  misunderstandings  where  the 


Ill 

employees  contribute,  to  make  the  system  inclusive  and  to  shape  it  so  as 
to  meet. problems  in  management. 

Of  course  not  all  of  the  150,000  to  200,000  Illinois  wage-earners  in 
plants  in  which  benefit  systems  are  in  operation  are  members  of  the 
funds.  It  has  been  possible  to  secure  accurate  figures  for  both  the  mem- 
bership and  the  total  number  of  wage-earners  in  Illinois  plants  in  only 
88  cases.  Combining  the  figures  for  the  88,  the  number  of  members  was 
found  to  be  about  65  per  cent  of  the  total  employed.  Taken  separately 
the  percentages  varied  from*  24  as  the  minimum  to  100  as  the  maximum. 

In  connection  with  membership  in  these  benefit  systems  it  should 
be  said  that  two  opposing  tendencies  have  been  present.  The  one  re- 
sults from  the  desire  to  make  the  membership  inclusive  so  as  to  ac- 
complish the  greatest  good  and  to  spread  the  overhead  cost  of  the  system 
as  widely  as  possible.  The  other  results  chiefly  from  the  desire  to  limit 
membership  so  as  to  avoid  bad  risks  who  would  draw  more  in  benefits 
than  they  would  contribute  in  dues  to  the  fund,  to  avoid  extending  aid 
in  unworthy  cases  and  to  avoid  association  with  those  racially  different. 
Out  of  these  and  other  cooperating  factors  have  developed  a,  maze  of 
varying  rules  and  practices. 

Xaturally  membership  in  the  systems  organized,  conducted  and 
supported  by  the  employers  is  more  or  less  inclusive.  In  18  funds 
supported  partly,  and  in  most  cases  largely,  by  the  members,  membership 
is  compulsory  for  those  admissible  under  the  rules.  In  some  other 
cases  the  pressure  upon  employees  exerted  through  "100  per  cent  drives" 
or  otherwise,  is  such  as  to  approach  compulsory  membership.  Where 
compulsion  or  pressure  is  absent,  which  is  most  frequently  the  case,  the 
membership  in  the  benefit  system  is  likely  to  be  less  general.  How 
general  it  is  among  the  employees  depends  upon  numerous  factors  such 
as  the  interest  displayed  in  securing  new  members,  the  terms  on  which 
they  secure  benefits,  the  nature  of  the  benefits  provided,  and  other 
opportunities  available  for  insurance. 

On  the  other  hand,  medical  examination  and  rejection  of  "chronics" 
and  other  undesirable  risks  are  found  in  44  of  the  115  funds  studied. 
In  a  few  other  cases  no  benefits  are  paid  in  cases  of  disability  due  to 
certain  chronic  diseases.  Persons  suffering  from  venereal  disease  are 
usually  excluded  from  membership  or  disability  due  to  venereal  disease, 
and,  perhaps,  disability  due  to  intemperance  and  immoral  conduct  are 
uncompensated.  In  26  cases  rules  are  found  debarring  the  older  appli- 
cants from  securing  admission  to  the  fund.  Eleven  funds  exclude 
women;  four  have  race  limitations.  In  a  large  number  of  cases  the 
applicant  must  have  been  employed  in  the  establishment  for  a  certain 
length  of  time  and  in  a  few  of  these  the  period  required  is  such  as  to  be 
very  restrictive  of  membership.  Salaried  employees  or  those  in  certain 
departments  may  be  excluded.  More  important,  in  order  to  avoid  diffi- 
culties due  to  paying  the  usual  sum  as  the  cash  benefit,  whicli  would 
equal  or  exceed  the  earnings  of  some,  those  with  the  lowest  wages  are  ex- 
cluded in  a  few  cases. 

Taken  collectively  these  benefit  systems  partially  compensate  for 
wages  lost  by  reason  of  disabling  sickness  or  accident,  provide  funeral 


11^ 

benefits  and  life  insurance,  and  make  organized  provision  for  medical 
and  surgical  treatment,  hospital  care,  nursing,  medical  and  surgical 
supplies,  and  dental  and  maternity  care.  Thus  every  important  feature 
of  a  full-fledged  health  insurance  program  is  found.  But  taken  separ- 
ately in  no  case  are  all  of  the  benefits  thus  enumerated  provided.  In 
most  cases  only  cash  benefits  are  paid,  frequently  in  small  sums  for  a 
comparatively  short  time  in  cases  of  disabling  sickness;  in  only  a  few 
cases  are  extensive  medical,  nursing  and  dental  benefits  found.  S 

The  primary  object  of  the  establishment*  funds  has  been  to  pay  cash 
benefits  in  cases  of  disability  and  death.  Hence  all  but  three  (these 
are  hospital  funds)  of  the  115  studied  pay  cash  benefits  in  the  event  of 
more  or  less  seriously  disabling  sickness,  and  70  of  the  115  pay  a  stipu- 
lated sum  or  sums  in  the  event  of  death.  Only  17  provide  anything  more 
than  these  cash  benefits. 

The  "sick  benefits"  paid  in  a  few  cases  are  a  certain  percentage  of 
wages.  In  one  fund  applying  uniformly  in  a  large  number  of  plants, 
it  is  two-thirds  of  the  disabled  member's  normal  earnings.  In  many 
other  cases  benefits  are  graded  roughly  according  to  wages.  Sometimes 
they  vary  with  length  of  service.  Most  frequently,  however,  they  are 
N^a  uniform  sum,  say  $1  per  day  or  so  much  per  week.  Sixty- three  funds 
provide  fixed  benefits  ranging  from  about  $4  to  $14  per  week.  The 
majority  of  these  pay  from  $7  to  $10.  Fifty-one  of  the  funds  pay 
graded  benefits  ranging  from  $1.50  to  approximately  $20  per  week."^  In 
a  majority  of  these  cases  the  minimum  is  close  to  $3.50  per  week  and 
the  maximum  about  $11.50.  Taking  44  benefit  systems  where  complete 
information  was  secured,  $1,653,619  was  paid  in  1917  in  compensation 
for  1,265,846  days  of  disability — an  average  of  $1.31  per  day.  With 
the  higher  level  of  wages  obtaining  in  1917  this  w^as  less  than  50  per 
cent  of  the  average  daily  earnings. 

In  any  health  insurance  plan  the  waiting  period  before  benefits 
become  payable,  the  maximum  number  of  weeks  for  which  they  may  be 
paid,  and  the  kinds  of  disability  excluded  from  compensation  are  very 
important.  Among  the  establishment  funds  of  Illinois  no  close  approach 
to  uniformity  in  these  matters  is  to  be  found.  Waiting  periods  of  a 
half  day,  3  days,  6  days,  7  days,  and  14  days  are  found,  7  days,  however, 
being  more  frequently  found  than  any  other.  In  some  cases  when  dis- 
ability lasts  longer  than  the  days  constituting  the  waiting  period  and 
claims  may  therefore  be  presented,  payment  is  allowed  from  the  first  day 
of  illness;  in  other  cases  it  is  allowed  only  from  the  close  of  the  waiting 
period ;  while  in  still  other  cases  a  compromise  arrangement  is  made  and 
benefits  are  paid  for  the  days  constituting  the  waiting  period  but  at  a 
reduced  rate. 

Of  greatest  importance  is  the  number  of  weeks  for  which  benefits 
^  are  paid  for  any  one  disability  and  for  all  disabilities  a  member  may 
have  in  any  one  year.  The  maximum  numbers  in  Illinois  establishments 
for  any  one  disability  vary  from  2  to  104 ;  for  all  disabilities  in  any  one 
year,  from  2  to  52  weeks.  In  both  cases  the  maximum  most  frequently 
found  is  13  weeks.     Thirteen  weeks  is  a  rather  short  period  in  certain 

■•One  of  the  115  funds  did  not  report  information  on  tliis  i)oint. 


113 

types  of  cases,  and  just  those  most  likely  to  result  in  acute  distress.  If 
payments  begin  with  the  eighth  day  of  disability  the  number  of  days  of 
disability  compensated  with  a  13  weeks'  maximuni  will  be  about  85  per 
cent  of  what  it  would  be  with  26  weeks'  and  about  74.5  per  cent  of  what 
it  would  be  with  52  weeks'  maxim^um.^  The  difference  is  no  small  one 
and  it  is  of  course  all  found  in  the  payments  made  in  the  more  serious 
cases  lasting  longer  than  98  days.  A  number  of  the  funds,  however, 
have  arrangements  under  which  it  is  possible  to  extend  the  benefits  for 
a  longer  time  in  individual  cases.  Moreover,  it  is  the  policy  of  some 
firms  to  supplement  the  work  of  the  funds  and  to  give  further  aid  than 
the  rules  call  for. 

Fifteen  of  the  llo  benefit  systems  studied  make  provision  for  the 
payment  of  maternity  benefits.  This  is  a  very  considerable  percentage 
of  the  funds  which  have  women  members. 

Most  establishment  funds  make  provision  for  the  payment  of  death 
benefits.  This  is  true  of  70  of  the  115  studied.  These  benefits  are, 
with  few  exceptions,  a  small  funeral  benefit  of  $50  or  $100  but  in  two 
cases  the  sums  allowed  are  $200  and  $300  respectively.  As  another 
exception,  nine  funds  were  found  which  pay  something  more  than  funeral 
benefits — as  much  as  $1,000  or  even  $2,000.  In  a  very  few  (three) 
cases  provision  is  made  for  the  payment  of  a  funeral  benefit  in  the  event 
of  the  death  of  the  wife  or  other  dependent  of  a  member. 

In  connection  with  death  benefits  provided  by  the  establishment 
funds,  something  should  be  said  concerning  the  death  benefits  and  in- 
surance provided  by  the  firms  as  such.  Death  benefits  and  life  insurance 
as  well  as  old  age  pensions  find  an  important  place  among  the  employer's 
welfare  plans  which  are  becoming  of  more  frequent  occurrence  and  his 
plans  for  stabilizing  his  labor  supply.  Thirteen  of  the  firms  in  connection 
Avith  whose  plants  funds  are  in  operation,  were  found  to  have  taken  out 
group  life  insurance  policies  for  their  employees.  In  some  cases  this 
was  in  addition  to  burial  benefits  otherwise  provided;  in  others  it  was 
the  only  death  benefit  payable.  Moreover,  7  company  funds  were  found 
out  of  which  death  benefits  ranging  from  $100  to  $2,000  are  paid. 
These  are  usually  limited  to  employees  who  have  been  in  the  service  of 
the  given  firm  for  a  certain  length  of  time,  and,  moreover,  are  generally 
graded  according  to  the  period  of  service. 

As  stated  above,  medical,  nursing  and  dental  benefits  are  not  so 
frequently  provided  as  these  cash  benefits  which  have  been  thus  far  dis- 
cussed. Of  the  115  funds  studied,  17  provide  for  medical  treatment  of 
their  members,  and  in  about  three-fourths  of  these  cases  this  treatment 
is  extended  to  them  in  the  home  as  well  as  in  the  establishment  in  which 
they  are  employed.  In  13  cases  surgical  care  is  provided  but  in  some  of 
these  cases  this  amounts  to  little  more  than  "first  aid."  In  only  10 
cases  is  there  any  claim  to  furnishing  hospital  care.  Most  important 
of  these  10  are  the  three  hospital  associations  mentioned  above.  One 
large  fund  provides  sanitarium  care  for  the  tuberculous,  and  when  the 

s  See  Part  II  of  this  report,  Special  Report  II,  Table  VI  for  basis  for  compu- 
tation made. 

—8  H   I 


114 

52  weeks  benefit  period  expires  this  may  he  extended,  the  expense  being 
divided  between  the  fund  and  the  firm.  In  a  few  instances  provision  is 
made  by  the  fund  for  nursing  and  for  medical  supplies.  However,  these 
services  are  more  commonly  furnished  by  the  firm. 

More  extensive  than  the  provision  for  medical  benefits  made  by 
these  funds  is  that  made  by  the  firms  in  whose  establishments  they  are 
found.  Several  of  these  maintain  medical  departments;  in  some  cases 
medical  treatment  is  extended  to  employees  in  their  homes,  but  chiefly 
in  emergency  cases;  several  provide  nursing  service,  and  in  some  cases 
in  the  home  by  visiting  nurses  as  well  as  at  the  plant;  in  two  cases  ex- 
tensive dental  departments  are  maintained. 

A  further  question  of  interest  relates  to  the  support  of  these  benefit 
systems.  The  22  employees^  funds,  all  small,  are  supported  by  the  con- 
tributions of  their  members.  Over  .against  these,  the  11  employers' 
funds  are  supported  entirely  by  the  firms.  In  the  case  of  82  joint  funds, 
the  cost  is  shared,  but  usually  not  equally.  In  59  of  these  the  only  con- 
tribution made  regularly  by  the  employer  is  the  expense  incurred  through 
the  "check-off''  of  dues ;  in  5  fixed  sums  or  a  definite  amount  per  employee 
is  contributed  annually;  in  17  a  percentage  of  the  amount  by  the  em- 
ployees, this  percentage  varying  from  10  to  100  but  most  frequently 
fixed  at  25  per  cent.  Taking  50  of  these  joint  funds  making  complete 
financial  reports  for  1917,  the  sum  paid  in  was  $4,357,529,  or  $17.82 
per  member.  Of  this  amount  the  firms  contributed  $498,322,  or  11.4 
per  cent,  while  the  employees  contributed  $3,857,207,  or  88.6  per  cent. 
In  other  words,  the  firms  contributed  $2.03  and  the  employees,  $15.79 
of  the  $17.82 — the  total  contribution  per  member.  In  all  of  these  cases, 
however,  the  employers,  at  some  expense,  checked  off  dues  from  wages. 
In  36  cases  they  made  no  contribution  in  cash.  Taking  the  remaining 
14  cases,  the  firms  contributed  $498,322,  or  12.8  per  cent,  while  the 
employees  contributed  $3,397,595,  or  87.2  per  cent  of  the  $3,895,917 
paid  in.  This  comparison  is  not  entirely  fair  in  one  respect;  some  of 
these  firms  provided  for  a  limited  amount  of  medical  treatment.  Making 
due  allowance  for  this,  however,  it  can  be  said  that  except  for  the  11 
employers'  fund,  and  two  or  three  other  cases,  the  greater  part  of  the 
cost  of  providing  the  various  benefits  rests  upon  the  employees  insured. 

The  administration  and  support  of  these  benefit  funds  usually  go 
hand  in  hand.  The  members  control  and  administer  the  employees' 
funds  and  the  employers  control  and  administer  the  employers'  funds. 
The  arrangements  for  the  control  and  administration  of  the  joint  funds 
vary  greatly.  Ten  cases  were  found  where  the  expenses  are  shared  by 
the  firm  and  the  employees,  but  the  control  and  administration  are 
vested  entirely  in  the  firm.  In  46  cases  where  the  firm  bears  a  part  of 
the  cost  by  collecting  the  dues,  the  control  and  administration  are  in  the 
hands  of  the  members.  In  the  remaining  cases  both  the  firm  and  the 
members  have  representation  in  the  system  of  administration  set  up. 

This  is  a  brief  statement  of  the  facts  relating  to  establishment 
benefit  funds  in  Illin^ois  as  found  by  the  investigation  made.  A  number 
of  points  of  importance  involving  intensive  study  have  not  been  ade- 
quately investigated.     Whether  the  interests   of  the   insured   are   con- 


115 

served  by  the  administration^  how  much  objection  may  be  made  to  com- 
pulsion and  pressure  found  in  a  minority  of  cases,  how  far  some  of  these 
systems  may  handican  labor,  if  at  all,  in  securing  advances  in  wages, 
or  in  organizing,  cannot  be  stated  from  the  investigation  made.  It  may 
be  pointed  out,  however,  that  the  establishment  funds  do  not  constitute 
a  system.  The  employee,  w4th  unimportant  exceptions  in  respect  to  the 
death  benefits,  is  insured  only  so  long  as  he  retains  employment  in  the 
given  plant,  or,  possibly  with  the  same  firm. 

(3)   Trade  Union  Benefit  Systems. 

The  labor  organizations  of  the  State  provide  insurance  against  sick- 
ness and  accident  for  more  workmen  than  have  membership  in  establish- 
ment funds  and  provide  death  benefits  or  life  insurance  for  a  much 
larger  number. 

The  benefit  phase  of  unionism  has  been  extensively  developed. 
Eather  naturally  (if  strike  benefits  are  excluded  because  of  a  very  differ- 
ent character  and  object)  this  began  by  providing  death  benefits.  Later, 
with  the  Granite  Cutters'  Union  as  the  pioneer  among  national  organi- 
zations, insurance  against  sickness  and  accidents  was  provided  for  in  an 
increasing  number  of  cases.  Unemployment  benefi.ts  and  superannuation 
benefits  or  old  age  pensions  have  come  to  find  place  in  some  of  the 
systems  developed.  Taking  the  United  States  as  a  whole,  a  very  con- 
siderable majority  of  union  men  and  women  are  provided  with  death 
benefits  by  the  national  or  the  locafl  union  or  both,  as  are  a  considerable 
percentage  with  sick  and  accident  benefits.  The  provision  of  other 
benefits  has  not  been  so  extensively  made. 

The  provision  made  by  the  unions  has  grown  directly  out  of  the  need 
felt  for  meeting  systematically  the  burdens  connected  with  the  mis- 
fortunes of  wage-earners.  It  has  replaced  to  an  extent  the  extension  of 
aid  by  donations,  which  is  widely  practiced  where  systematic  provision 
has  not  been  made  or  proves  to  be  inadequate.  An  additional  motive  lead- 
ing to  the  emphasis  placed  by  some  organizations  upon  benefits  is  found 
in  their  value  in  attracting  and  holding  members.  They  may  aid  in  the 
extension  of  organization ;  experience  shows  their  value  in  conserving 
the  membership  built  up. 

Sickness  and  accident  benefits. — From  data  secured  by  correspond- 
ence and  from  reports  and  questionnaires,  it  is  estimated  that  in  Illinois 
there  are  somewhat  more  than  2,500  local  unions  with  a  membership  of 
410,000  or  more.  Approximately  41  per  cent  or  roughly  two-fifths  of 
these  members  are  connected  with  unions  maintaining  national  or  local 
sickness  and  accident  benefit  funds.  From  the  available  data  it  would 
appear  that  more  than  four-fifths  of  these  are  "beneficiary"  members. 
Hence  it  may  be  said  that  about  a  third  (135,000  to  145,000)  of  the 
members  of  labor  organizations  in  the  State  when  sick  are  entitled  to 
benefits  in  accordance  with  the  rules  under  which  funds  are  administered. 

In  some  cases  the  provision  for  paying  sickness  benefits  is  made  by 
the  national  or  international  union ;  in  others  by  the  local  union ;  and.  in 
some  cases  both. 

Of  the  nationals  and  internationals  providing  sickness  benefits, 
15   are  represented   in   Illinois  with   336   locals  and   33,208   members. 


116 

Some  of  the  locals  of  at  least  five  of  these  fifteen  organizations  provide 
additional  sickness  benefits.  As  against  this  rather  small  number  of 
unionists  there  are  perhaps  380,000  in  the  State  in  some  2,200  locals 
not  affiliated  with  the  nationals  or  internationals  which  provide  sickness 
benefits.  More  or  less  detailed  information  has  been  received  directly 
from  898  of  these  locals  with  194,524  members.  Of  these,  223  with 
70,443  members  were  found  to  have  made  provision  for  paying  benefits 
to  those  in  the  beneficiary  list  disabled  by  sickness.  It  is  from  the  data 
obtained  from  these  nationals  and  locals  that  the  above 'general  estimates 
have  been  made  and  the  facts  here  presented  have  been  selected. 

The  benefit  systems  maintained  by  unions  differ  greatly  in  im- 
portant details — those  relating  to  eligibility  to  the  "beneficiary"  class, 
waiting  period,  maximum  number  of  weeks  for  which  benefit  may  be  paid, 
and  the  amount  per  week.  There  are  no  well-defined  standards.  In- 
asHiuch  as  details  are  presented  elsewhere  in  this  report,^  only  the  more 
frequent  practice  will  be  set  forth  here. 

Most  frequently  membership  is  compulsory  upon  the  union  men  who 
can  meet  the  requirements  set  up.  Possibly  limitations  are  made  to 
exclude  those  who  are  over  a  certain  age,  or  who  have  a  chronic  disease, 
or  who  cannot  pass  a  medical  examination.  Likely,  dues  must  have 
been  paid  for  a  time,  most  irequently  for  from  3  to  6  months,  before 
claims  to  benefits  may  be  made.  All  such  requirements  are,  of  course, 
for  the  protection  of  the  funds. 

Taking  the  national  unions,  three-fifths  have  a  waiting  period  of 
7  days,  the  others  14  days.  Benefits  are  paid  in  sums  varying  from  $3 
to  $12  per  week,  with  $5  as  the  most  usual  rate.  This,  as  already  indi- 
cated, is  sometimes  added  to  by  the  locals.  The  maximum  period  for 
which  benefits  may  be  paid  varies  from  six  weeks  to  two  years,  with 
three  months  as  the  most  common  period. 

Among  the  local  unions  in  the  State  reporting  to  the  Commission, 

18  per  cent  have  no  waiting  period;  2  per  cent  a  waiting  period  of  less 
than  7  days;  53  per  cent  7  days;  14  per  cent  14  days;  the  remaining  10 
per  cent,  with  one  exception  with  21  days,  waiting  periods  of  more  than 
7  but  less  than  14  days.  The  range  of  benefits  paid  is  about  the  same  as 
among  the  national  unions,  with  an  average  of  about  $1  per  day  which 
is  at  present  of  course  not  as  much  as  25  per  cent  of  the  average  earnings 
(of  union  men) .  In  respect  to  the  maximum  number  of  weeks  for  which 
benefits  are  paid,  practically  the  same  range  is  found  as  among  the 
nationals  except  that  it  in  some  cases  falls  below  six  weeks. 

In  connection  with  what  has  Just  been  said  concerning  the  maxi- 
mum periods  for  which  benefits  may  be  paid,  it  should  be  stated  that 

19  national  and  international  unions  with  111,185  members  in  Illinois, 
provide  for  benefits  in  case  of  permanent  disability.  These  are  as  a 
rule,  however,  disabilities  resulting  chiefly  from  industrial  accident. 
Yet  such  disabilities  as  paralysis  are  included.  The  benefits  vary  up- 
ward from  $50,  and  usually  depend  upon  the  length  of  membership  or 
the  amount  of  dues  paid.  In  some  cases  the  payment  made  is  in  lieu 
of  a  death  benefit. 


«/Sfee  Part  II,  Special  Report  XII. 


117 

There  is  almost  complete  absence  of  medical  and  hospital  care  among 
national  and  local  union  funds.  Only  four  of  the  locals  report  attending 
physicians  paid  by  the  unions.  A  few  state  that  hospital  care  and  surgi- 
cal treatment  are  furnished  in  case  of  need.  Only  one  well-developed 
organization  for  providing  hospital  treatment  has  been  found — a  co- 
operative miners'  hospital  at  West  Frankfort.  This  is  a  first  class 
hospital,  managed  by  a  board  of  trustees  from  am»ng  the  miners,  with 
a  staff  of  physicians  and  nurses.  It  cares  for  both  the  miners  and  the 
members  of  their  families,  the  expenses  being  met  by  the  local  unions. 

The  administration  of  the  union  fund  is  usually  in  the  hands  of  the 
regular  union  officials,  with  a  "sick  visiting  committee."  There  is 
practically  no  cost  of  administration.  When  local  the  fund  has  the 
further  advantage  of  a  certain  amount  of  elasticity  in  handling  claims. 
Some  of  the  nationals  have  experienced  some  difficulty  in  malingering 
and  in  excessive  claims  presented  in  times  of  wide-spread  unemployment. 
N"one  seems  to  have  tried  the  plan  of  dividing  the  cost  between  the 
national  treasurv  and  that  of  the  local  so  as  to  secure  the  active  co- 
operation  of  the  locals  in  administering  claims.  The  chief  difficulty 
(other  than  the  malingering  reported  in  some  cases)  experienced  by  the 
locals  has  been  due  to  the  poor  equipment  in  the  great  majority  of  cases 
for  doing  the  necessary  administrative  work.  The  provision  of  benefits 
is  after  all  an  incident  in  the  union's  affairs. 

How  much  advance  the  unions  may  make  in  providinng  sickness 
benefits  is  difficult  to  say.  Such  provision  is  instituted  by  new  locals 
each  year;  at  any  given  time  a  large  percentage  of  the  systems  will  be 
found  to  have  been  in  operation  only  a  relatively  short  time.  Over 
against  the  cases  of  provision  newly  made,  are  found  a  considerable 
number  where  that  which  had  been  made  has  been  discontinued  as  in- 
volving administrative  difficulty,  or  "too  much  bother,"  or  as  requiring 
too  heavy  dues.  Moreover,  it  may  be  said  that  there  is  a  wide-spread 
feeling  among  union  men  that  benefit  systems  make  for  conservatism  and 
may  stand  in  the  way  of  a  vigorous  program  of  higher  wages  and  shorter 
hours. 

Death  benefits. — Combining  data  at  hand  it  may  be  estimated  that 
approximately  7  in  8  of  the  members  of  unions  in  Illinois  belong  to 
organizations  paying  death  benefits  or  providing  life  insurance  out  of  the 
local,  state,  or  national  funds.  In  some  cases  a  small  funeral  benefit  is 
paid  also  in  the  event  of  death  of  the  wife,  or  dependent  mother,  or  child. 

Our  investigations  show  that  64  nationals  and  internationals  with 
1,591  locals  and  combined  membership  of  229,046  in  Illinois,  provide 
funeral  benefits  or  life  insurance  ranging  from  $20  to  $4,500.  In 
between  ten  and  fifteen  per  cent  of  the  cases  the  locals  add  a  second 
benefit  to  this.  Prominent  among  the  internationals  not  providing  a 
death  benefit  is  the  United  Mine  Workers  of  America.  In  this  case 
the  State  organization  (District  XII)  pays  a  death  benefit  of  $250. 
Where  neither  the  national  nor  the  State  organization  makes  provision 
of  this  kind,  our  data  from  locals  would  indicate  that  about  as  frequently 
as  not  such  provision  is  made  by  them. 


118 


"  Perhaps  a  distinction  should  be  made  between  the  life  insurance 
provided  by  a  minority  of  the  nationals  and  internationals  and  the  death 
benefit  commonly  paid.  Nine  unions  with  a  membership  of  35,506  in 
the  State  write  insurance  contracts,  the  insurance  usually  being  com- 
pulsory for  those  who  can  pass  the  necessary  medical  examination  and 
who  are  not  over  a  stated  age.  The  insurance  policies  usually  vary  from 
$300  to  $1,000  at  ftie  one  extreme  and  from  $1,500  to  $4,500  at  the 
other.  The  ordinary  death  benefit  is,  however,  $50  or  $100,  but  in  some 
cases  it  is  as  much  as  $500  for  members  long  in  the  union. 

(4)  Insurance  by  Fraternal  Orders. 

Most  important  of  all  institutions  providing  insurance  for  wage- 
earners  and  their  families  are  the  fraternal  societies.  In  fraternal 
membership  Illinois  ranks  first  among  the  commonwealths.  On  Decem- 
ber 31,  1917  the  fraternal  orders  providing  life  insurance  and  regulated 
under  the  insurance  laws  of  the  State  had  1,043,469  members.  To  this 
membership  must  be  added  that  of  a  number  of  orders  which  do  not 
provide  life  insurance  but  some  of  which  do  provide  health  insurance. 
Using  the  data  made  available  by  the  Insurance  Department  and  by 
questionnaires  and  conferences  the  Commission  estimates  that  the  fra- 
ternal orders  provide  insurance  of  one  or  more  kinds  for  at  least  750,000 
persons — men,  women  and  children — of  the  wage-earning  group  in  Illi- 
nois. The  orders,  taken  collectively,  provide  life  insurance  and  death 
benefits,  "whole  family  protection^^  (juvenile  life  insurance),  old  age  and 
disability  benefits,  sick  and  accident  benefits,  medical  treatment  and 
maternity  benefits.  And,  as  is  well-known,  they  frequently  make  dona- 
tions to  meet  needs  not  covered  by  insurance.  This  aid  must  be  kept  in 
mind  in  connection  with  this  summary  of  fraternal  insurance."^ 

Of  the  various  kinds  of  personal  insurance,  life  insurance  and  death 
benefits  have  been  most  emphasized  by  the  fraternal  orders  as  a  whole. 
The  growth  of  their  membership  and  business  has  been  rapid  in  the 
United  States.  The  Insurance  Year-Book  reported  the  insurance  written 
by  489  of  them  in  1901  at  $799,626,678;  the  number  of  certificates  at  the 
end  of  the  year  wa^  4,518,955,  their  amount  $5,655,453,465.  Ten  years 
later  the  reports  for  397  showed  $1,200,633,063  written  during  the 
year,  10,122,169  certificates  outstanding,  their  amount  $9,839,909,282. 
jMore  recently  their  life  insurance  has  been  seriously  aifected  by  the  war 
situation.  The  new  insurance  written  in  1917,  according  to  the  in- 
surance Year-Book  (1918  edition),  was  $822,041,734;  the  number  of  cer- 
tificates outstanding,  7,456,551 ;  the  amount  of  insurance  $9,129,974,447. 

A  like  movement  has  taken  place  in  Illinois.  On  December  31, 
1917,  149  fraternals  were  authorized  to  write  life  insurance  in  the  State. 
These  149  had  a  total  membership  of  1,043,469,  a  majority  of  whom  are 
wage-earners  or  members  of  their  families.  The  amount  of  insurance 
in  force  December  31,  1917  was  $1,164,545,418;  the  amount  collected 
from  members  during  the  year  for  "mortuary  indemnity  and  expense 
purposes,'^  $15,298,170;  the  amount  paid  out  in  settlement  of  claims 
in  Illinois,  $14,086,344. 

■^  For  a  full  account  of  fraternal  insurance,  see  Part  II  of  this  report,  Special 
Report  VII. 


119 

Most  of  the  fraternal  life  insurance  in  Illinois  is  on  the  lives  of 
adults.  However,  previous  to  1917  a  few  of  the  orders  had  provided  for 
the  payment  of  funeral  benefits  in  the  event  of  death  of  dependent 
children  of  members.  The  last  General  Assembly  added  an  act^  to  the 
statutes  relating  to  fraternal  life  insurance  organizations  and  author- 
izing them  under  certain  conditions  to  issue  policies  providing  "wholo 
family  protection."  This  Act  authorizes  fraternal  beneficiary  societies 
to  organize  and  operate  branches  for  the  payment  of  death  or  annuity 
benefits  upon  the  lives  of  children  between  2  and  18  years  at  next  birth- 
day. The  funds  of  such  branch  are  to  be  kept  distinct  from  the  other 
funds  of  the  beneficiary  society,  and  are  to  be  obtained  from  special  dues 
or  assessments  and  are  to  be  based  upon  one  of  two  experience  tables. 
The  maximum  benefits  are  limited  by  a  scale  incorporated  in  the  law, 
the  scale  varying  from  $34  for  those  2  years  of  age,  to  $600  for  those 
16  to  18  years  of  age.  This  business  cannot  be  entered  upon  or  con- 
tinued with  fewer  than  500  certificates. 

The  object  of  this  law  was  to  authorize  fraternal  beneficiary  societies 
to  provide  insurance  for  the  dependent  children  of  their  members  cor- 
responding to  that  written  by  companies  writing  industrial  life  insurance. 
In  the  late  summer  of  1918,  it  was  found  that  of  the  149  societies  author- 
ized to  write  life  insurance  in  the  State,  27  with  311,273  members  had 
taken  steps  to  provide  this  "whole  family  protection."  At  least  9  of 
these  with  150,952  members  had  already  placed  the  plan  in  operation. 

The  fraternal  societies  are  of  course  democratic,  cooperative,  non- 
profit-seeking organizations.  That  life  insurance  is  provided  by  them  in 
substantial  amounts  is  shown  by  the  figures  presented  above ;  the  amount 
of  insurance  provided  on  7,456,551  certificates  in  effect  in  the  United 
States  as  a  whole  December  31,  1917  was  $9,129,974,447,or  an  average  of 
approximately  $1,224  per  certificate.  The  one  important  shortcoming, 
and  it  is  as  important  as  it  is  unfortunate,  is  that  in  spite  of  an  im- 
provement in  this  respect,  the  majority  of  the  fraternal  societies  are  not 
on  an  actuarially  sound  basis. 

Many  of  the  older  fraternals  undertook  to  provide  their  members 
with  life  insurance  because  of  their  belief  in  the  mutual  principle  and 
in  protest  against  the  stock  companies  with  their  reserves,  their  (then) 
treatment  of  withdrawing  policyholders,  and  alleged  frequent  cases  of 
mismanagement.  The  early  societies  collected  assessments  as  needed  to 
meet  their  obligations;  sound  actuarial  principles  were  disregarded. 
Indeed,  the  slogan  "keep  your  reserves  in  your  pockets"  was  much  used, 
and  with  the  inevitable  result  that  many  societies  became  bankrupt  and 
expected  insurance  was  lost.  Learning  by  experience,  an  increasing 
number  of  the  older  societies  have  made  an  effort  to  get  upon  a  sound 
basis  and  those  more  recently  organized  have  tried  to  avoid  the  mistakes 
of  the  earlier  time.  However,  it  has  been  a  difficult  matter  to  repair  the 
injury  wrought  by  the  disregard  of  sound  insurance  principles.  Many 
societies  have  struggled  with  the  problem  without  complete  success;  and 
there  have  been  not  a  few  laggards.  The  result  is  that  to-day  the  ma- 
jority of  fraternals  do  not  have  sufficient  assets,  including  receipts  from 

*Act  relating  to  Fraternal  Beneficiary  Societies,  approved  June  25,  1917,  Laws 
of  Illinois,  Fiftieth  General  Assembly,  1917,  pp.   544-546, 


120 


dues  being  collected,  to  cover  their  liabilities.  In  other  words,  the 
-majority  of  the  fraternals  cannot  meet  the  test  applied  to  the  stock  com- 
panies under  the  insurance  laws. 

"  According  to  the  most  recent  report  of  the  Commissioner  of  In- 
surance of  Wisconsin,  12  of  20  societies  organized  under  the  laws  of  that 
state  and  27  of  36  organized  under  the  laws  of  other  states,  in  1917,  did 
not  have,  as  evaluated,  "total  assets  available  for  payment  of  future  death 
claims"  sufficient  to  cover  the  "total  net  value  of  outstanding  certificates 
(required  reserve)."^  Indeed  a  very  considerable  number  had  a  small 
percentage  of  the  required  (adequate)  reserve.  Though  a  majority  of 
the  societies  found  here  have  taken  steps  to  place  themselves  upon  an 
actuarially  sound  basis,  the  situation  in  Illinois  is  not  materially  differ- 
ent from  that  in  Wisconsin. 

Insurance  commissioners  and  general  organizations  of  fraternal 
societies  have  given  much  attention  to  the  problem  presented  by  numer- 
ous actuarially  unsound  orders.  One  outcome  was  the  so-called  "Mobile 
Bill"  adopted  in  1910  by  the  National  Convention  of  Insurance  Com- 
missioners. In  1911  this  was  revised  and  amended  and  given  shape  in 
what  is  called  the  New  York  Conference  Bill.  The  measure  was  de- 
veloped in  conference  with  the  representatives  of  the  National  Fraternal 
Congress  and  the  Associated  Fraternities  of  America.  At  the  beginning 
of  1918  the  New  York  Conference  Bill,  amended  in  some  cases,  was  in 
effect  in  28,  the  Mobile  Bill  (without  the  New  York  Conference  Amend- 
ments), in  4  states.  Six  other  states  have  legislation  or  insurance 
rulings  based  upon  the  same  principles'^  as  the  New  York  Conference 
Bill.  Illinois  does  not  appear  in  the  list  of  38  states  with  legislation  or 
rulings  designed  to  meet  the  problem. 

The  New  York  Conference  Bill,  in  effect  in  28  of  the  states,  is 
designed  to  induce  or  to  compel  progress  by  the  fraternal  societies  towards 
an  actuarially  sound  basis.  It  provides  for  a  valuation  of  the  certificates 
of  each  society.  If  this  valuation  in  any  case  showed  that  the  present 
value  of  future  net  contributions,  together  with  admitted  assets  of  Decem- 
ber 31,  1917  were  less  than  the  present  value  of  the  promised  benefits  and 
accrued  liabilities,  then  such  society  must  maintain  said  financial  con- 
dition at  each  succeeding  triennial  valuation.  If  the  subsequent  valu- 
ations do  not  show  at  least  as  good  condition  the  insurance  department 
"may  proceed  to  cancel  the  societ3^'s  license,  or  begin  proceedings  for  the 
society's  dissolution."  Thus,  the  object  is  to  bring  about  a  gradual 
improvement  in  the  condition  of  those  fraternals  whose  condition  is  un- 
satisfactory. It  is  important  that  the  laggards  should  be  caused  to  make 
progress  in  this  direction  for  actuarial  unsoundness  not  only  means  un- 
certain life  insurance  but  also  causes  many  persons  not  to  join  these 
societies  so  as  to  obtain  life  insurance  or  the  other  benefits  which  many 
of  them  provide.  Control*  of  the  unsound  society  not  only  protects  the 
certificate  holders,  but  also  makes  fraternal  societies  in  general  more 
attractive  to  those  eligible  to  membership  in  them. 

» See  Wisconsin,  Commissioner  of  Insurance,  Fraternal  Benefit  Societies.  Ex- 
tract from  Forty-ninth  Annual  Report,  pp.  3-25.  The  methods  of  valuation  em- 
ployed are  there  shown. 

"Pacts  taken  from  the   1918   edition   of  Statistics  Fmternal   Societies,  p.  207. 


121 

* 

It  has  been  found  that  at  least  39  of  the  fraternal  societies  author- 
ized to  write  life  insurance  in  Illinois,  provide  specific  indemnities  for 
loss  of  limb,  loss  of  sight,  loss  of  hearing,  or  other  disabilit}'.  These 
societies  (December  31,  1917)  had  in  Illinois  a  membership  of  255,881, 
or  about  one-fourth  of  the  total. 

Funeral  benefits,  as  distinguished  from  life  insurance,  are  sometimes 
provided  by  the  local  lodges.  All  told  they  have  been  found  among  the 
local  lodges  of  33  societies,  but  chiefly  among  those  with  German, 
Swedish,  Polish  or  other  members  of  mother  tongue  other  than  English. 
In  some  cases  the  provision  of  funeral  benefits  is  made  compulsory  upon 
the  local  lodges,  but  in  most  cases,  it  is  left  optional  with  them.  Where 
optional  the  provision  of  funeral  benefits  does  not  seem  to  make  a  strong 
appeal,  no  doubt  because  of  the  general  provision  of  insurance  in  more 
substantial  sums.  As  reported  to  the  Commission,  the  funeral  benefits 
range  in  amount  from  the  cost  of  carriage  or  automobile  hire  and 
flowers  for  the  funeral  to  $100,  with  amounts  of  $50  or  $75  perhaps 
more  frequently  than  any  other. 

Much  more  important,  for  the  Commission's  purposes,  than  the 
insurance  thus  far  mentioned,  are  the  health  and  accident  benefits  pro- 
vided by  the  fraternal  societies.  In  spite  of  extensive  investigations 
and  numerous  conferences  by  its  investigators  with  organizations  and 
fraternal  officers,  the  Commission  is  able  to  make  only  the  roughest 
estimate  of  the  number  of  wage-earners  and  their  dependents  provided 
with  health  and  accident  benefits  by  the  fraternal  societies  of  this  State. 
It  has  secured  data  from  117  of  the  149  societies  supervised  by  the  State 
because  they  provide  life  insurance  and  from  10  other  societies  which 
are  not  so  supervised  because  they  provide  only  disability  benefits.  It 
has  secured  returns,  also,  from  1,871  of  4,900  local  chapters  of  these 
societies  to  which  questionnaires  were  sent  because  the  grand  lodges 
were  unable  to  furnish  desired  information  with  reference  to  any 
health  and  accident  insurance  they  (the  locals)  provided  for  their 
members. 

It  has  been  found  that  at  least  32  of  the  grand  lodges,  with  146,493 
members,  provide  sick  and  accident  benefits.  In  some  cases  all  eligible 
members  are  insured,  while  in  other  cases  only  those  who  so  elect  be- 
come beneficiary  menabers.  It  is  estimated  that  of  the  146,493  members, 
60,000  had  health  and  accident  insurance,  and  that  approximately  40,000 
of  these  were  of  the  wage-earning  class.  It  was  found  that  17  of  the  life 
insurance  orders  and  4  others,  with  a  combined  membership  of  203,549, 
made  the  provision  of  sickness  and  accident  benefits  compulsory  upon 
their  local  chapters.  In  most  of  these  cases  all  who  were  eligible  were 
beneficiary  members.  From  the  data  at  hand  it  is  estimated  that  175,000, 
of  whom  approximately  115,00i)  were  of  the  wage-earning  class,  had 
insurance  in  these  local  lodges.  Again,  it  was  found  that  56  societies 
with  742,553  members  made  it  optional  with  their  local  chapters  to  pro- 
vide sick  and  accident  benefits.  From  the  data  obtained  from  question- 
naires it  is  estimated,  roughly,  that  local  chapters  with  a  combined 
membership  of  150,000  to  200,000,  provided  such  insurance  for  their 
beneficiary  members,  numbering  perhaps  between  100,000  and  150,000. 


^ 


122 

0-f  these  perhaps  75,000  to  105,000  would  be  of  the  wage-earning  class. 
It  was  found,  finally,  that  neither  the  grand  lodge  nor  the  local  chapters 
of  19  societies  provided  health  or  accident  insurance.  Thus,  data  were 
secured  from  127  societies  and  a  considerable  number  of  their  locals. 
The  total  membership  of  the  127  societies  was  1,223,054.  It  is  roughly 
estimated  that  from  350,000  to  400,000  of  these  were  provided  with 
health  and  accident  insurance  by  the  grand  lodge  or  by  the  local  chapters 
or  by  them  jointly,  and  that  perhaps  between  70  and  75  per  cent  of 
these  were  of  the  wage-earning  class. 

In  order  to  ascertain  the  number  of  wage-earners  provided  with 
health  insurance  by  fraternal  societies  it  would  be  necessary,  first,  to  add 
a  small  figure  for  the  societies  from  which  no  data  were  obtained,  then, 
secondly,  to  make  deductions  for  duplication  of  membership  in  two  or 
more  societies  and  for  insurance  of  non-wage-earning  members  of  wage- 
earning  families.  Obviously  it  is  difficult  to  make  proper  allowances 
for  these  three.  In  the  light  of  data  at  hand,  however,  the  number  of 
wage-earners  provided  with  health  and  accident  insurance  by  fraternal 
societies  is  placed  between  225,000  and  275,000. 

Except  for  death  benefits  and  life  insurance,  the  one  important 
benefit  provided  by  fraternal  societies,  whether  by  the  grand  lodge  or  by 
the  local  chapter  or  by  the  two  jointly,  is  for  loss  of  earnings  caused  by 
disabling  sickness  or  accident.  As  a  rule  the  "loss  of  time"  benefit 
paid  makes  no  discrimination  between  sickness  and  accident  cases,  ex- 
cept, perhaps,  in  the  payment  of  lump  sums  in  cases  of  specific  injury 
sustained.  In  describing  the  insurance  provided  it  will  be  well  to  dis- 
cuss the  provision  made  by  grand  lodges  first  and  then  that  made  by  the 
local  organizations. 

Just  how  much  the  grand  lodges  spend  in  sick  and  accident  benefits 
in  Illinois  cannot  be  estimated  accurately  from  the  Insurance  Eeport 
because  ot"tJie  inclusion  of  other  items  with  these.  However,  using  the 
data  in  the  report  covering  1917,  in  the  light  of  data  obtained  directly  by 
the  Commission,  it  would  appear  that  something  over  $200,000  was  spent 
in  settling  about  6,500  sick  and  accident  claims  in  Illinois.  The  range 
of  benefits  paid  by  the  grand  lodges  as  reported  to  the  Commission, 
was  from  $2.50  per  week  as  a  minimum  to  $120  per  month  as  a  maxi- 
mum. Seventeen  of  the  societies  reported  benefits  which  vary  in  amount 
in  accordance  with  the  dues  paid  by  the  insured  member  or  in  accord- 
ance with  this  factor  and  the  occupational  or  other  hazard.  One 
society  offers  benefits  of  $4,  $6,  $8  or  $10  per  week;  a  second,  $5,  $7.50, 
-$10  or  $15  per  week;  a  third,  $1,  $2,  or  $3  per  day;  a  fourth,  benefits 
varying  from  $15  to  $100  per  month.  In  two  cases  the  benefits  paid 
by  the  grand  lodge  begin  after  they  have  been  paid  for  3  months  or  6 
months  by  the  local  chapter.  The  other  societies  report  waiting  periods 
varying  from  1  day  to  2  weeks,  but  fixed  at  7  days  in  a  majority  of  the 
cases.  The  maximum  benefit  period  (for  payment  of  .the  normal  rate) 
varies  from  10  weeks  to  5i/^  years,  but  is  most  frequently  15,  16  or  26 
-  weeks  in  the  year.  In  several  instances,  however,  a  smaller  benefit  is 
paid  for  a  second  period  after  the  period  for  payment  at  the  full  rate 
has  expired. 


123 

It  is  evident  from  this  brief  summary  that  there  are  great  variations 
in  the  standards  observed  in  the  health  insurance  provision  made  by  the 
grand  lodges.  This  is  equally  true  of  the  local  lodges  whether  the 
provision  is  made  compulsory  upon  or  is  optional  with  them. 

As  has  been  indicated,  many  more  wage-earners  and  their  de- 
pendents are  provided  with  health  and  accident  insurance  by  local  lodges 
than  by  the  grand  lodges.  No  record  is  available  of  how  much  is  paid 
out  in  benefits  by  these  local  lodges.  The  benefits  paid  have  been  found 
to  vary  from  $2  to  $12  per  week.  Most  frequently  they  are  $3  or  $5  or 
$7  per  week,  or  $1  per  day.  There  are  also  great  variations  in  the 
waiting  periods  and  in  the  number  of  weeks  for  which  benefits  may  be 
paid.  The  most  frequent  waiting  period  is,  however,  one  week.  The. 
maximum  number  of  weeks  in  the  year  for  which  benefits  may  be  paid 
is  most  frequently  13,  but  a  maximum  of  26  weeks  is  not  uncommon. 
Nor  are  shorter  periods  uncommon,  maxima  of  only  6  weeks  being 
found. 

Thus  it  may  be  said  that  the  sickness  benefits  provided  by  fraternal 
societies  are  far  from  being  standardized.  It  may  be  said,  also,  that  the 
provision  made  by  the  locals  is  on  the  whole  less  generous  than  that 
made  by  the  grand  lodges.  It  is  evident^  moreover,  that  most  of  the 
benefits  paid  are  relatively  small.  Of  course  where  the  management  is 
good  the  members  collectively  get  in  benefits  most  that  they  pay  in  dues 
for  the  expenses  of  administration  are  relatively  low  and  these  societies 
are  non-profit-making  institutions.  The  benefits  are  generally  small 
because  dues  are  low.  The  dues  are  low  because  the  members  do  not 
feel  able  or  do  not  care  to  pay  more  for  health  and  accident  insurance. 
The  amount  paid  in  dues  is  more  frequently  50  cents  per  month  than 
any  other  sum.  However,  in  some  cases  it  is  as  much  as  $1  per  month, 
while,  on  the  other  hand,  the  local  chapters  of  one  large  society  collect 
only  50  cents  per  quarter  from  those  insured  against  sickness  and 
accident. 

About  one  grand  lodge  in  eight  provides  for  the  payment  of  total 
and  permanent  disability  benefits.  Among  those  reporting  to  the  Com- 
mission were  sixteen  which  pay  sick  benefits  for  permanent  and  total 
disability  arising  either  from  sickness  or  accidental  injury,  the  sums 
paid  varying  gr-eatly  from  one  society  to  the  other.  In  some  of  these 
cases  the  sums  paid  are  charged  against  the  life  insurance  carried ;  in  a 
very  few  they  are  provided  as  an  additional  benefit  under  life  insurance 
carried;  in  most  cases,  however,  the  members  have  the  option  of  secur- 
ing such  insurance  by  the  payment  of  additional  dues. 

In  describing  the  health  and  accident  benefits  provided  by  fraternal 
organizations,  attention  should  be  called  to  restrictions  designed  to  safe- 
guard the  funds  against  "bad  risks."  The  '^^insurance  orders"  require  a 
medical  examination  as  a  condition  of  admission.  Where  disability 
benefits  are  not  provided  incidental  to  life  insurance,  medical  examin- 
ation is  generally  required  for  admission  to  the  special  fund.  Again, 
in  many  cases  benefits  are  not  paid  or  are  paid  at  a  reduced  rate  in  cases 
of  chronic  disease.  Moreover,  benefits  are  not  as  a  rule  paid  where  the 
disability  is  due  to  immoral  conduct.  Again,  age  limitations  are  found 
in  connection  with  the  rules  relating  to  the  admission  of  members,  those 
over  50,  55,  or  60,  say,  not  being  accepted.     Furthermore,  in  some  cases 


124 

insurance  against  disability  ceases  automatically  at  a  given  age,  say  50 
or  60,  or  benefits  are  paid  only  at  a  reduced  rate. 

A  considerable  number  of  the  local  lodges  providing  cash  benefits 
in  cases  of  disabling  sickness  or  accident,  provide  medical  care,  and, 
now  and  then,  nursing  service  and  hospital  treatment  as  well.  From 
data  at  hand  it  would  appear  that  less  than  a  fifth  of  the  locals  paying  a 
cash  benefit  provide  medical  care  also.  Where  medical  care  is  provided 
it  is  given  by  the  "lodge  doctor"  who  is  most  frequently  paid  $1  or  $2 
per  member  per  year.  It  seems  to  be  the  general  opinion  among 
doctors  that  this  "lodge  practice''  does  not  as  a  rule  result  in  efficient 
treatment  of  the  sick. 

Mne  of  the  fraternal  orders  reporting  to  the  Commission  provide 
maternity  benefits.  One  of  these  pays  a  lump  sum  of  $10,  and  the 
regular  sick  benefit  for  any  disability  lasting  more  than  30  days  after 
confinement.  Another  pays  a  sum  twice  as  large  as  the  weekly  sick 
benefit.  A  third,  under  a  new  "law"  adopted  in  1917,  pays  a  lump  sum 
of  $50,  the  funds  required  being  obtained  from  dues  paid  by  those  in- 
sured for  this  special  benefit. 

These,  stated  in  summary  form,  are  the  benefits  of  immediate  inter- 
est to  this  Commission,  provided  by  fraternal  organizations.  The  frater- 
nal societies  are  of  first  importance  in  providing  health  insurance  for 
the  members  of  the  wage-earning  group  in  Illinois. 

(5)   Foreign  Benefit  Societies. 

With  insurance  by  fraternal  orders  discussed,  little  need  be  said 
concerning  the  benefit  systems  maintained  by  independent  foreign 
societies,  for  these  societies  are  merely  local  fraternals  organized  on  a 
race  (or  language)  basis.  The  main  differences  between  these  societies 
and  the  fraternals  discussed  above  are  due  to  the  facts  that  the  former 
are  small  and  much  more  unstable  than  the  latter  and  are  entirely  un- 
regulated under  the  insurance  laws  of  the  State. 

The  population  of  Illinois  contains  a  large  percentage  who  are 
foreign  born  and  of  mother-tongue  other  than  English.  Prominent 
among  them  the  Germans,  the  Scandinavians,  the  Italians,  the  Poles 
and  the  Bohemians  may  be  mentioned.  When  of  recent  immigration, 
they  tend  strongly  to  organize  their  own  societies  for  various  purposes, 
among  them  to  make  provision  to  meet  the  problems  connected  with 
sickness,  accident  and  death.  Such  societies  are  found  in  largest  num- 
bers in  Chicago,  but  are  found  in  smaller  numbers  in  other  industrial 
centers  where  any  considerable  group  of  a  non-English  speaking  race 
reside  and  work.  Elsewhere  in  this  volume  a  special  report  is  pre- 
sented setting  forth  the  results  of  a  special  investigation  of  typical 
societies  studied  in  Chicago. ^^  In  general  the  results  apply  equally  well 
to  North  Chicago,  Waukegan  and  other  places  where  similiar  organi- 
zations exist. 

Excluding  singing  societies,  athletic  clubs  and  the  like,  a  list  has 
been  prepared  of  approximately  600  independent  foreign  societies  in 
Chicago.  Of  these  approximately  half  have  political,  educational  or 
social  interests  only.  The  others,  totaling  313,  add  to  such  interests 
as  these  benefits  of  various  kinds.     A  study  has  been  made  of  161  of 

^^See  Part  II,  Special  Report  X. 


125 

these  313,  their  combined  membership  being  21,024,  or  an  average  of 
about  130  each.  Of  the  IGl,  34  had  fewer  than  50  and  85  fewer  than 
100  members;  only  19  had  as  many  as  300  and  only  5  as  many  as  500 
members.  The  small  membership  of  most  of  them  is  an  important  fact. 
If  those  studied  are  typical  of  the  larger  number  the  membership  of 
independent  foreign  benefit  societies  in  Chicago  would  be  something 
more  than  40,000. 

As  would  be  expected,  most  interest  is  displayed  in  death  benefits. 
No  fewer  than  125  of  the  161,  with  18,336  members,  pay  death  benefits, 
most  frequently  in  the  sums  of  $50  or  $100,  or  a  similar  sum  derived 
from  an  assessment  levied  upon  the  membership.  The  minimum  sum 
found  was  $15,  the  maximum  $250;  the  average  amount  paid  in 
250  cases  in  1917  was  approximate^  $145.  In  short,  most  of  the  mem- 
bers of  these  foreign  societies  are  provided  with  funeral  benefits.  Here 
and  there  smaller  sums  are  provided  in  the  event  of  death  of  wife  or 
other  dependent. 

Only  less  important  is  the  provision  for  paying  cash  benefits  in  cases 
of  sickness  and  accident,  whether  occupational  or  non-occupational. 
Such  provision  was  found  in  95  societies  with  12,070  members  or  about 
57  per  cent  of  the  combined  membership  of  the  benefit  societies  studied. 
As  would  be  expected,  the  systems  were  found  to  be  multi-form;  no 
approach  to  a  well-defined  standard  had  developed.  Some  require  a 
medical  examination  as  a  condition  of  admission  to  the  system  main- 
tained, others  do  not.  Some  have  very  short  waiting  periods,  a  large 
number  a  waiting  period  of  7  days,  some  a  waiting  period  as  long  as  2 
wrecks.  Some  pay  benefits  from  the  first  day  of  disability,  others  from 
the  end  of  the  w^aiting  period.  Seven  pay  benefits  for  a  "normal"  period 
of  not  to  exceed  six  weeks;  44  for  more  than  6  but  not  to  exceed  13 
weeks;  43  for  more  than  13  but  not  to  exceed  26  weeks;  one  for  a  longer 
period.  Of  the  95,  32  pay  benefits  at  a  reduced  rate,  usually  half  of  the 
normal  sum,  for  a  second  benefit  period.  The  "normal'^  benefit  varies 
all  the  way  from  $2.50  to  $15  (in  one  case)  per  week.  It  is  not  in  excess 
of  $5  in  71  cases ;  more  than  $5  but  not  in  excess  of  $10  in  22.  Thus 
it  would  appear  that  the  benefits  are  usually  comparatively  small.  The 
rates  have  been  fixed  in  view  of  the  once  small  earnings  of  the  immi- 
grant and  have  become  more  or  less  customary.  Another  factor  enter- 
ing in  is  that  only  small  dues  can  be  collected  and  these  will  support 
only  small  cash  benefits. 

Comparatively  few  of  the  societies  have  made  systematic  provision 
for  medical  or  hospital  treatment.  However,  of  the  161,  19  with  2,545 
members,  have  '^society  doctors'^  to  provide  medical  treatment,  the 
most  usual  arrangement  taking  the  form  of  a  per  capita  fee  of  $1  per 
year.  One  Croatian  and  8  Greek  societies  with  1,535  members  had  made 
arrangements  for  needed  hospital  care.  In  some  cases  the  entire  bill  is 
paid;  in  others  from  $7  to  $15  per  week  is  paid  for  six,  eight,  ten, 
twelve,  twenty-six,  or  (in  three  cases)  an  indefinite  number  of  weeks. 

This  is  a  brief  statement  of  the  systematic  provision  these  inde- 
pendent foreign  societies  have  made  for  meeting  the  problem  they  find 
connected  with  sickness,  accident  and  death.  It  is  important  to  note, 
however,  that  they  do  not  limit  their  mutual  aid  to  the  settlement  of 
insurance  claims.     These  and  the  non-benefit  societies,  like  trade  unions 


126 

and  other  mutual  organizations,  extend  aid  more  or  less  liberally  out- 
side of  the  insurance  departments  which  may  have  been  set  up. 

As  a  result  of  the  investigation  undertaken  it  was  hoped  definite 
information  would  be  obtained  relating  to  the  actuarial  soundness  and 
fitness  of  these  organizations  in  other  respects  to  serve  as  insurance 
carriers.  This  hope  has  been  realized  only  to  a  slight  extent.  It  can 
,  be  said,  however,  that  most  of  them  are  too  small  and  too  short-lived  to 
provide  life  insurance  in  small  amounts  without  great  risk  of  dis- 
appointment, or  to  develop  able  management.  There  is  more  or  less 
failure  to  observe  good  insurance  principles,  and  now  and  then  funds 
have  been  lost  through  failures  of  private  banks  in  which  they  are  fre- 
quently deposited,  or  by  unwise  investment.  The  most  important  fact 
is,  however,  that  they  are  small  and  unstable  organizations.  Though 
the  organization  mortality  cannot  be  measured,  because  of  the  absence 
of  lists  of  these  societies  for  earlier  times,  the  information  secured  from 
well-informed  men  supports  the  usual  assertion  to  the  effect  that  it  is 
very  high.  They  appear,  and,  for  the  most  part,  sooner  or  later  dis- 
appear as  independent  organizations.  Many,  to  the  advantage  of  their 
members,  affiliate  with  national  fraternal  orders.  Many  die.  Perhaps 
the  members  move  away  from  the  community  as  other  immigrant  races 
move  in  or  the  old  members  die  and  their  native  offspring  do  not 
generally  join  the  foreign  organization.  In  all  probability  dues  have 
not  been  based  upon  the  whole  life  of  the  member,  the  needed  succession 
of  young  lives  is  not  forthcoming,  the  average  age  of  the  members  in- 
creases and  the  risks  become  greater,  with  the  inevitable  result  that  the 
institution  is  not  in  a  position  to  compete  on  good  terms  with  other 
insurance  carriers.  Decay  and  dissolution  and  loss  of  expected  death 
benefits  are  naturally  of  more  frequent  occurrence  among  these  inde- 
pendent foreign  societies  than  among  other  organizations  providing 
insurance. 

If  the  foreign  societies  were  more  generally  founded  on  good  in- 
surance principles,  w^ere  larger,  and  there  was  a  greater  guarantee  of 
efficient  management,  their  value  would  be  distinctly  greater  because  of 
a  more  successful  appeal  to  those  eligible  to  membership  and  the  less 
frequent  cases  of  disappointment  and  loss. 

(6)  The  Health  and  Accident  Business  of  Casualty  Insurance  Com- 
panies and  Assessment  Associations. 

As  another  type  of  carrier  of  health  and  accident  insurance  we  have 
the  casualty  and  assessment  companies,  and  the  stock  life  insurance 
companies  which,  upon  compliance  with  certain  conditions,  may  engage 
in  the  health  and  accident  business.  Some  of  the  policies  written  cov6r 
sickness  only,  others  accident  only,  and  still  others  both  sickness  and 
accident.  A  rather  detailed  account  of  this  insurance  will  be  found 
elsewhere  in  this  report.^^  Here  only  a  brief  summary  of  the  business 
of  the  casualty  companies  and  assessment  associations  will  be  presented, 
and  that  part  of  it  taking  the  form  of  liability  insurance  and  written 
for  employers  will  be  excluded  because  not  in  point. 

The  time  of  our  investigations  made  it  necessary  to  use  data  for 
the  year  1917.     On  December  31  of  that  year  76  casualty  companies 

"  See  Part  II,  Special  Report  VI. 


127 

were  authorized  to  write  health  and  accident  insurance  in  Illinois.  The 
best  estimate  we  have  been  able  to  make  from  existing  reports  and  re- 
turns to  questionnaires  is  that  in  1917  these  companies  had  approxi- 
mately 250,000  health  and  accident  policies  in  effect  in  this  State.  The 
number  of  policy-holders  would  be  somewhat  less  for  some  carry  more 
than  one  policy.  It  would  appear  that  a  majority  of  them  are  business 
men,  professional  men,  farmers,  and  others  of  the  non-wage-earning 
classes.  It  would  perhaps  be  not  inaccurate  to  say  that  about  100,000 
of  the  Illinois  holders  of  the  health  and  accident  policies  outstanding 
against  the  companies  December  31,  1917  were  wage-earners,  or  of 
wage-earning  families.  Most  of  these  are  the  more  highly  paid  wage- 
earners,  chiefly  mechanics  and  other  skilled  laborers. 

The  health  and  accident  policies  of  casualty  companies  may  be 
classified  as  "commercial"  and  "industrial."  Commercial  policies  com- 
monly provide  weekly  benefits  to  compensate  for  loss  of  time  from  dis- 
ability due  to  sickness  or  accident,  as  the  case  may  be,  ranging  from  $10 
to  $50  or  more  and  other  benefits  correspondingly  high,  and  are  usually 
sold  on  the  annual  premium  plan.  Industrial  policies  provide  smaller 
benefits,  ranging  from  $20  to  $125  per  month  for  total  disability  result- 
ing from  accident  or  disease,  and  are  usually  sold  on  the  monthly 
premium  plan  although  some  are  purchased  by  quarterly  and  many  by 
weekly  premiums.  The  commercial  policies  are  designed  to  meet  the 
needs  and  preferences  of  business  and  professional  men  and  the  better- 
paid  salaried  employees.  The  industrial  policies,  as  the  name  suggests, 
are  intended  to  attract  wage-earners.  For  the  greater  part  the  policies 
are  individual.  Insurance  of  groups  of  workmen  is  comparatively  new 
and  as  yet  not  extensive.  This  phase  of  insurance  will  be  discussed  in  a 
later  section  (8)   of  this  chapter. 

Health  insurance  formerly  sold  by  casualty  companies  insured 
against  disability  resulting  from  only  a  limited  number  of  diseases, 
which  were  of  course  enumerated  in  the  policy,  but  contracts  which 
insure  against  nearly  all  diseases  are  now  sold  by  most  companies. 
Complaints,  misunderstandings,  incisive  criticism  by  insurance  com- 
missioners and  competition  among  the  companies  have  caused  the  policies 
to  be  liberalized  so  that,  taken  as  a  whole,  they  are  materially  different 
from  what  they  once  were.  The  policies  most  frequently  employed  ex- 
clude disability  due  to  venereal  disease,  diseases  not  common  to  both 
sexes,  and  a  few  other  causes  of  no  special  importance  in  so  far  as  wage- 
earners  are  concerned.  Limited  policies,  insuring  against  disability 
arising  from  one  or  more  of  a  certain  number  of  diseases,  or  excluding 
disability  due  to  certain  diseases  (such  as  tuberculosis)  not  mentioned 
above  are  sold.  It  should  be  stated  here,  also,  though  it  is  mentioned 
below,  that  different  rules  may  be  applied  to  disabilities  due  to  different 
diseases,  those  of  frequent  occurrence  and  whose  duration  is  likely  to 
be  long  being  treated  less  liberally  than  others  under  the  insurance 
contract. 

In  deciding  as  to  the  eligibility  of  an  applicant  for  health  or  acci- 
dent insurance  casualty  companies  consider  sex,  age,  race,  physical 
characteristics  and  condition,  occupation,  place  of  residence,  other  health 
or  accident  insurance  carried  by  him  and  the  relation  between  his  in- 


128 

come  and  the  total  benefit  which  he  could  claim  under  all  policies  carried 
in  case  he  were  disabled  by  illness  or  acidental  injuries.  Applicants  are 
generall}-  inspected;  doubtful  risks  are  given  medical  examination. 

Some  companies  insure  "male  risks^'  only;  others  accept  "female 
risks''  under  contracts  drawn  exclusively  for  women ;  while  others  insure 
men  and  women  on  the  same  terms.  The  companies  which  discriminate 
against  women  assert  that  they  are  more  frequently  disabled,  or  that 
they  present  a  greater  problem  in  malingering  and  simulation;  or  that 
the  recorded  experience  is  inadequate  to  serve  as  a  basis  for  scientific 
rates  for  them.  Usually  those  under  18  or  over  60  or  65  are  not  ac- 
cepted for  health  policies;  those  up  to  70  are  commonly  accepted  for 
accident  policies.  The  data  at  hand  indicate  that  some  of  the  companies 
do  not  accept  as  risks  those  of  certain  races.  A  number  have  stated 
that  their  experience  had  been  so  unfortunate  in  insuring  persons  of 
one  or  more  of  certain  races  specified  that  they  no  longer  accepted  them 
as  risks.  Those  engaged  in  certain  hazardous  occupations  are  not  ac- 
cepted, but  these  non-insurable  occupations  are  comparatively  few.  Some 
companies  have  reported  that  they  write  no  business  in  certain  com- 
munities because  of  unsatisfactory  health  or  moral  conditions.  More 
frequently  the  business  does  not  extend  to  a  community  because  the 
prospective  profit  is  not  sufficiently  attractive. 

Health*  and  accident  policies  are  renewed  by  payment  of  the 
premiums.  They  lapse  with  failure  to  pay.  They  may,  however,  be  can- 
celled by  the  company  at  any  time  by  returning  the  unearned  premium, 
and  they  are  frequently  cancelled  when  risks  prove  to  be  bad  or  unsatis- 
factor}",  because  of  frequent  disability  or  submission  of  unwarranted 
claims. 

Under  the  health  and  accident  policies  sold  by  casualty  companies, 
various  benefits  ("indemnities"  they  are  usually  called)  may  be  pro- 
vided. The  most  important,  in  fact  the  only  important  one,  is  that 
for  "loss  of  time."  The  amount  of  the  benefit  per  week  or  month  is 
stipulated  in  the  contract,  but  in  order  to  prevent  over-insurance,  it  is 
ordinarily  fixed  in  a  sum  less  than  the  income  of  the  insured.  Perhaps 
it  will  be  not  in  excess  of  half,  or  two-thirds  or  three-fourths  of  his  in- 
come. It  is  likely,  however,  to  be  larger  than  the  benefits  paid  by  es- 
tablishment"  or  trade  union  funds.  The  insurance  company  wishes  to 
write  the  largest  possible  policy  with  the  necessary  margin  of  safety, 
while  the  establishment  and  union  funds  most  frequently  use  a  more  or 
less  customary  sum  fixed  in  vieAv  of  the  minimum  cost  of  living.  The 
industrial  policies  most  frequently  sold  provide  for  monthly  "indem- 
nities" of  $45  or  $50  for  "total  disability."  Policies  providing  for 
indemnities  as  low  as  $20  per  month  are  not  uncommon,  however,  while 
some  providing  benefits  as  high  as  $100  or  $125  per  month  are  sold.  In 
some  cases  the  rate  of  benefit  increases  with  the  life  of  the  policy.  This 
is  designed  to  reduce  the  number  of  lapses. 

The  commercial  policies  most  frequently  sold  in  Illinois,  in  case  of 
"total  disability,^'  provide  benefits  for  a  period  limited  to  52  weeks. 
Benefits  under  most  industrial  policies  are  limited  to  6  or  8  months. 
These  are  the  more  usual  maximum  periods  for  disabilities  due  to  one  or 
more  of  most  diseases.     The  organized  insurance  business  is  conducted 


129 

for  profit,  and  many  of  the  policies  restrict  the  payment  of  the  usual 
weekly  or  monthly  benefit  in  the  case  of  certain  chronic  diseases  and 
diseases  of  long  duration  to  a  fraction  of  the  maximum  period.  Thus 
one  rather  liberal  policy  with  a  twelve  months  maximum  limits  payments 
in  cases  of  paralysis,  tuberculosis,  cancer  and  locomotor  ataxia  to  six 
months.  Another  policy,  with  six  months  as  the  maximum  in  any 
twelve,  limits  the  benefits  to  one  month  in  any  one  policy  year  in  case 
the  insured  suffers  total  disability  by  reason  of  rheumatism,  tuberculosis, 
paralysis,  neurasthenia,  sciatica,  Bright's  disease,  apoplexy,  locomotor 
ataxia,  cancer,  neuritis,  sprains  or  strains,  lumbago,  orchitis,  hernia,  or 
any  chronic  disease.  Some  policies  carry  a  still  longer  list  of  diseases 
for  which  the  indemnity  is  limited  to  a  fraction  of  the  usual  period. 
These  are  serious  limitations  from  the  point  of  view  of  adequacy,  though 
the  lower  premium  paid  for  such  policies  may  give  as  much  protection 
for  the  money  paid  as  is  given  by  the  more  liberal  policies  sold  at  higher 
rates. 

"Total  disability"  usually  means  one  that  confines  the  injured  to 
the  house  or  prevents  him  from  attending  to  his  business  or  occupation. 
Payments  are  made  upon  a  doctor's  certificate.  The  law  of  Illinois  re- 
quires that  upon  request  of  the  insured  payment  shall  be  made  at  least 
once  in  every  60  days  of  half  or  more  of  the  "indemnity"  which  has 
accrued  since  the  last  pajnnent  and  that  any  balance  remaining  unpaid 
at  the  termination  of  the  period  for  which  the  insurance  company  is 
liable  shall  be  paid  immediately  upon  receipt  of  due  proof.  Most  of 
the  policies  sold  in  Illinois  provide  for  the  payment  of  installments  of 
the  benefit  every  30  or  60  days. 

Less  important  than  that  just  described  are  the  partial  disability, 
the  convalescent,  hospital,  operation,  nursing,  and  blindness  and  paralysis 
or  other  permanent  disability  benefits  provided  more  or  less  frequently 
under  health  and  accident  policies.  Most  policies  provide  either  the  first 
or  the  second  of  these,  the  first  for  a  limited  period,  usually  falling 
within  the  maximum  for  total  disability,  the  second  usually  limited  to 
one  or  two  months  under  industrial  policies,  and  both  at  perhaps  half  the 
rate  paid  in  case  of  total  disability.  Many  of  the  policies  provide  for 
partial  or  complete  reimbursement  of  the  insured  for  his  hospital  ex- 
penses, and  cost  of  operations.  The  allowance  for  operations  is  usually 
according  to  a  scale  the  figures  in  which  are  lower  than  the  fees  com- 
monly charged  by  surgeons.  The  hospital  "indemnity,"  usually  limited 
to  3  months  under  industrial  policies,  may  be  the  usual  weekly  benefit  or 
a  fraction  of  that  sum.  These  two  indemnities  are  frequently  exclusive ; 
only  the  one  or  the  other  may  be  claimed.  Payment  to  cover  nursing 
care  is  infrequently  provided  for  and  in  non-hospitalized  cases ;  the  other 
indemnities,  including  medical  treatment  in  cases  of  non-confining 
sickness,  may  be  passed  over  as  of  little  importance  in  showing  the 
general  character  of  this  health  insurance.  The  variations  found  in  the 
treatment  of  accident  cases  need  not  be  set  out.^^ 

The  health  insurance  provided  by  casualty  companies  differs  eo 
greatly  from   that  provided  by  the   establishment   funds,   unions   and 

•    "An    of   these    are    adequately   presented    In    Part    II    of   this    report,    Special 
Report  VI. 

— 9  H  I 


130 


fraternal  orders  that  few  comparisons  can  be  made  between  them. 
Moreover,  there  is  no  well-defined  standard  observed  by  any  one  set  of 
carriers.  It  may  be  said,  however,  that  the  policy  contracts  of  the  in- 
surance companies  have  been  liberalized  until  their  provisions  are  on  the 
whole  as  liberal  in  their  coverage  as  the  provisions  of  most  of  the  other 
carriers.  Whether  we  consider  establishment  funds,  union  benefit  systems, 
fraternal  orders  or  casualt}^  companies  frequent  instances  are  found  in 
which  those  disabled  by  reason  of  certain  diseases  are  not  insured.  In  re- 
spect to  the  maximum  period  during  which  the  benefits  may  be  claimed 
and  the  rate  paid,  the  insurance  provided  by  casualty  companies  appears 
more  nearly  adequate.  On  the  other  hand,  however,  the  casualty  com- 
pany as  a  business  institution  disposes  of  claims  in  more  strict  accord- 
ance with  the  provisions  of  the  insurance  contract.  This  is  not  neces- 
sarily the  case  with  the  local  fraternal  order,  the  establishment  fund, 
and  the  union  fund.  Here  there  is  more -elasticity  and  a  freer  hand  in 
administering  the  benefits  so  as  to  take  care  of  needy  cases.  The  chief 
advantage  these  carriers  have  over  the  company  carrier  is,  however, 
found  in  the  net  cost  of  the  insurance  provided. 

The  premiums  paid  for  policies  written  by  casualty  companies  can- 
not be  compared  directly  with  the  dues  paid  into  funds  of  these  other 
carriers  because  of  difi^erences  in  the  protection  afforded.  Moreov^er, 
while  the  dues  charged  by  other  carriers  are  commonly  fixed  without 
regard  to  age,  the  premiums  charged  by  casualty  companies  increase  with 
age  over  fifty  because  of  the  greater  hazard.  Again,  the  premiums 
charged  by  casualty  companies  vary  widely  because  of  differences  in 
occupational  hazards.  Yet  a  few  comparisons  can  be  made  between 
what  the  insured  pay  and  what  they  get  collectively.  If  the  diversion  of 
union  insurance  funds  to  other  purposes  is  excepted,  the  insured  receive 
back  what  they  pay  in  less  the  cost  of  administration  which  is  most  fre- 
quently less  than  10  per  cent  and  not  infrequently  only  1  per  cent  or 
nothing.  In  the  case  of  establishment  funds  the  relation  between  sums 
paid  "in  and  the  amount  paid  out  varies  with  the  method  of  support,  but 
unless  wages  are  kept  on  a  lower  plane  because  of  the  benefit  system 
maintained,  even  in  those  cases  where  the  members  are  the  only  con- 
tributers  to  the  fund,  all  but  a  small  percentage  of  what  is  paid  in  by 
all  is  paid  out  in  benefits  to  the  disabled.  The  fraternal  carriers  com- 
pare favorably  with  the  unions.  In  the  case  of  the  casualty  companies, 
however,  the  insurance  is  expensive  and  for  obvious  reasons. 

Combining  the  figures  for  Illinois  business  as  reported  by  casualty 
companies  to  the  Superintendent  of  Insurance  for  the  four  years  1913- 
1916,  it  is  found  that  the  health  and  accident  premiums  (net)  collected 
amounted  to  $12,655,973.18,  the  losses  paid  to  $5,300,176.55.  The 
ratio  of  losses  paid  to  premiums  collected  was  41.88  for  the  four  years. 
The  premiums  collected  in  1917  were  $3,848,485;  the  losses  paid 
$1,891,894;  the  ratio  of  losses  paid  to  premiums  collected  49.16.  Hence 
it  may  be  said  that  less  than  50  cents  on  the  dollar  has  been  returned 
by  the  casualty  companies  to  policyholders  in  Illinois;  during  these 
years  more  than  50  cents  plus  the  additions  made  to  the  collections 
through  investment  has  gone  to  the  companies  to  cover  the  expenses  of 
business  acquisition,  the  expenses  of  management — both  of  which  are 


131 

necessarily  large,  and  to  constitute  profit  on  the  business,  or  has  been 
added  to  the  necessary  reserve  fund.  Making  allowance  for  the  reserve 
fund  perhaps  half  of  the  premiums  have  not  been  returned  or  credited 
to  the  policyholders. 

The  reason  why  this  kind  of  insurance  is  so  expensive  is  found 
chiefly  in  the  great  cost  of  acquisition  when  individual  policies  are 
written.  The  agents,  competing  for  "prospects,'^  must  necessarily  be 
paid  high  commissions.  In  the  language  of  the  profession  this  insurance 
is  sold,  not  bought.  The  insured  are  not  grouped  as  employees  of  a  firm, 
or  as  members  of  a  union  or  fraternal  order.  Prospects  must  be  visited 
individually  in  the  home  or  at  the  place  of  work.  Moreover,  it  is  said 
"statistics  show  that  one  out  of  every  ten  prospects  properly  approached 
becomes  a  policyholder."^'*  Again,  the  premiums  due  from  policy- 
holders must  be  collected.  The  '^Accident  Insurance  ManuaP  for  1918 
states  (p.  4)  that  "relatively  the  commissions  paid  to  the  sellers  of  in- 
come insurance  *  *  *  ^pg  higher  than  are  paid  to  salesmen  in  any 
other  legitimate  calling,"  and,  further,  that  "the  renewal  commissions, 
that  is,  the  compensation  paid  to  those  who  have  originally  sold  this 
necessary  of  life  and  who  have  placed  the  annual  or  semiannual  renewal 
of  the  contract,  are  constant — not  reduced,  as  in  other  forms  of 
insurance." 

A  tabulation  of  the  reports  (for  their  entire  business)  submitted 
by  35  companies  doing  business  in  Illinois  and  reporting  the  health 
business  separately  shows  that  in  1917  they  received  $9,925,041.55  in 
net  premiums  and  paid  out  $2,756,799.37,  or  27.78  per  cent  of  this  sum 
in  commissions  and  brokerage.  A  like  tabulation  of  the  reports  sub- 
mitted by  22  companies  reporting  health  and  accident  insurance  com- 
bined shows  that  they  received  $13,744,294  in  net  premiums  and  paid 
out  $4,100,018.15,  or  29.8-  per  cent  of  this  sum  in  commissions  and 
brokerage.  These  percentages  are  averages.  The  commissions  (when 
straight  fees  are  paid  and  not  a  commission  and  a  policy  fee)  sometimes 
run  above  40  per  cent,  sometimes  as  low  as  ten  per  cent,  but  most  fre- 
quently approximate  30  per  cent  or  30  cents  on  the  dollar  collected.  At 
any  rate  such  is  the  conclusion  arrived  at  from  an  examination  of  sworn 
returns  made  to  the  Insurance  Department  of  Wisconsin  two  years  ago. 

Voluntary  insurance  written  on  individual  policies  is  and  must  be 
expensive  because  of  the  conditions  under  which  it  is  carried  on.  Partly 
because  it  is  expensive  the  lapse  ratio  is  high.  Twenty-four  of  the 
companies  reported  to  the  Commission  with  reference  to  the  life  of  their 
policies.  The  average  longevity  of  commercial  policies,  according  to 
these  reports,  would  probably  be  about  three  years;  that  of  the  in- 
dustrial policies  between  six  months  and  one  year. 

From  the  survey  made  for  the  Commission  it  would  appear  that 
though  health  insurance  written  by  casualty  companies  is  comparatively 
new  and  the  great  majority  of  wage-earners  are  still  ignorant  of  such 
merits  as  it  has,  it  cannot  be  expected  to  become  general  if  written  on 
individual  policies  and  not  combined  with  life  insurance.  Several 
suggestions  have,  however,  been  made  for  writing  it  in  group  form. 
This  is  discussed  briefly  in  section  '8'  of  this  chapter. 

"  See  Part  II,   Special  Report  VI. 


132 


The   assessment   associations,    unlike   the   casualty   companies,    are 
mutual  organizations  operative  on  the  assessment  basis,  and  without  a 
capital   stock.     Under  the   Illinois   law  they   are   authorized  to   write  j 
health  and  accident  insurance  and  to  provide  a  funeral  benefit  of  not 
to  exceed  $100. 

In  1917  there  were  22  assessment  associations  writing  insurance  in 
Illinois.  At  the  end  of  the  year  they  had  228,000  certificates  in  force; 
during  the  year  they  received  from  their  members  for  indemnity  and 
expense  purposes  the  sum  of  $2,067,324,  and  paid  in  death,  permanent 
disability,  sick  and  accident  claims  the  sum  of  $1,032,312.37.  i^bout 
75  per  cent  of  this  latter  sum  was  in  settlement  of  sickness  and  accident  j 
claims;  most  of  the  remaining  25  per  cent  was  paid  out  in  death  or 
funeral  benefits. 

Though  a  number  of  these  associations  write  insurance  chiefly  for 
wage-earners  and  a  few  of  them  employ  the  weekly-premium  method, 
no  fewer  than  178,875  of  the  228,000  certificate  holders  mentioned 
above,  were  members  of  organizations  limiting  themselves  exclusively  or 
almost  entirely  to  the  insurance  of  business  men  and  commercial 
travelers.  Of  the  remaining  49,155  certificate  holders,  not  to  exceed 
40,000  were  of  the  wage-earning  group. 

In  essentials  the  health  and  accident  insurance  provided  by  these 
associations  is  very  much  the  same  as  that  provided  by  casualty  com- 
panies. While  it  may  be  somewhat  cheaper,  as  claimed  by  the  officers 
of  the  associations,  the  expenses  of  some  of  the  organizations  special- 
izing in  industrial  insurance  are  relatively  heavy,  and  the  amounts  ex- 
pended are  small  in  comparison  with  the  amounts  collected.  In  one  ex- 
treme case  the  collections  in  four  years  totalled  $134,922;  the  Gum 
spent  in  the  payment  of  death,  sickness  and  accident  claims  was  $41,075 ; 
the  commissions  and  fees  paid  to  its  agents  aggregated  $51,969 ;  the 
salaries  paid  to  various  officers  amounted  to  $30,495.  Another  asso- 
ciation during  this  same  period  collected  $225,859  from  its  members 
and  paid  $53,130  on  account  of  claims  presented. 

From  the  data  available  it  appears  that  the  number  of  lapses  is 
large.  Leaving  out  the  organizations  providing  insurance  chiefly  for 
business  men  and  commercial  travelers,  the  number  of  policies  written, 
restored,  or  revived  in  1917  was  64,733;  the  number  terminated  (chiefly 
by  lapse),  45,334;  the  number  in  effect  at  the  end  of  the  year,  49,155. 

(7)   Industrial  Life  Insurance. 

Among  the  many  subjects  under  investigation  by  this  Commission, 
that  of  industrial  life  insurance  has  been  of  special  interest  for  it  is 
written  chiefly  on  the  lives  of  wage-earners  and  the  members  of  their 
families  and  is  designed  to  provide  "funds  necessary  to  assure  a  decent 
burial  and  the  expenses  for  medical  attendance  during  last  illness.''^^ 

The  industrial  life  insurance  business  of  the  older  companies  now 
engaging  in  it  dates  from  the  1870's— about  45  years  ago.  It  has 
grown  rapidly  in  the  United  States  especially  during  the  last  fifteen 
years,  until  in  1918  the  number  of  industrial  policies  in  force  has  been 
estimated   at   38,000,000.i«     The   aggregate   amount   of   industrial   life 

15  Quoted  from  Huebner.  Life  Insurance,  p.   275. 
i«  The  Spectator,  December  12,   1918,  p.   23. 


133 

insurance  in  force  January  1,  1918  was  reported  at  $5,223,415,465;^^ 
by  the  end  of  the  year  it  no  doubt  approximated  five  and  a  half  billions. 
A  large  proportion  of  wage-earning  families  now  make  use  of  it,  and  it 
is  more  frequently  found  among  them  than  the  insurance  provided  by 
any  other  carrier.  In  this  Illinois  is  no  exception  to  the  rule.  With 
11  companies  writing  industrial  policies  at  that  time,  the  number  in 
force  in  the  State  December  31,  1916,  was  2,306,458.  The  amount  of 
industrial  insurance  was  $306,616,086,  which  gives  an  average  of  $132.94 
per  policy.  It  is  safe  to  say  that  making  allowance  for  the  fact  that  a 
considerable  number  of  policyholders  carry  two  or  moi'C  policies,  there 
were  at  that  time  approximately  2,000,000  holders  of  industrial  insurance 
policies,  and  that  the  great  majority  were  wage-earner^  and  their 
dependents. 

Industrial  life  insurance  stands  in  contrast  to  "ordinary  life'"'  in 
several  respects.  Premiums  on  it  are  collected  weekly  and  at  the  home ; 
on  "ordinary  life"  they  are  usually  paid  semi-annually  or  annually  and 
at  the  main  office.  The  principal  is  adjusted  to  the  weekly  premium 
(3,  5,  10  or  15  cents,  etc.)  in  the.  case  of  industrial  insurance;  the 
premium  is  adjusted  to  the  principal  in  the  case  of  "ordinary  life."  In- 
dustrial life  is  written  for  both  adults  and  children,  while  "ordinary 
life"  is  written  on  the  lives  of  adults  only.  Some  of  the  above  contrasts 
are  of  importance  in  connection  with  points  to  be  discussed  below. 

Industrial  life  insurance,  unless  it  is  permitted  to  lapse,  is  a  certain 
method  of  providing  funds  for  the  last  illness  and  for  burial.  The  num- 
ber who  discontinue  their  insurance  is  by  no  means  small.  Yet  the 
number  of  lapses  in  a  year  except  among  the  newer  policy-holders  where  it 
is  great,  is  not  large  for  unless  a  more  substantial  amount  of  insurance 
can  be  carried,  this  minimum  is  very  much  desired.  Moreover,  the 
agents  are  very  much  interested  in  preventing  lapses,  for  their  remuner- 
ation varies  directly  with  the  net  amount  they  add  to  their  total  of 
weekly  premiums.  The  chief  criticism  made  of  industrial  life  insurance 
is,  however,  that  it  is  expensive. 

Now  and  then  comparisons  are  made  of  the  greatly  different  amounts 
of  protection  secured  for  a  given  outlay  from  industrial  and  from  ordi- 
nary policies.  Such  comparisons  have  only  a  limited  value,  however, 
for  the  risks  differ  greatly.  Partly  because  of  the  less  careful  selection  of 
policyholders  and  partly  because  of  the  higher  mortality  among  wage- 
earners  and  other  classes  for  whom  industrial  insurance  is  written,  "the 
number  of  Industrial  deaths  per  100,000  policyholders  exceeds  the  num- 
ber of  ordinary  deaths  at  the  same  ages  all  the  way  from  about  20  to  50 
per  cent."^^ 

More  frequently,  in  this  connection,  comparisons  are  made  between 
premiums  collected  and  death  claims  paid.^^  Thus  in  Illinois  during 
the  six  years  1911  to  1916,  the  premiums  received  on  industrial  policies 
amounted  to  $50,572,117.48,  the  losses  paid,  to  $14,180,624.68.  The 
corresponding  figures  for  1917  were  $11,360,001.28  and  $3,470,266.45. 

^^  Ibid.,  September,   12,   1918,  p.   143. 
"  See  Part  II  of  this  report.  Special  Report  VIII. 

^^  See  especially  Report  on  Health  Insurance,  Massachusetts  Commission,   1917, 
p.  33. 


Thus  the  losses  paid  mmng  the  period  1911-1916  .were  28.04  per  cenTT 
in  1917,  30.05  per  cent  of  the  premiums  collected.  Such  comparisons, 
however^  greatly  exaggerate  the  difference  between  what  the  policyholders 
pay  to  the  company  and  what  they  in  return  receive  from  it,  for  they  fail 
to  take  into  consideration  dividends,  surrender  values,  and  necessary 
reserves. 

The  large  companies  now  writing  industrial  life  insurance  have 
been  mutualized;  perhaps  90  per  cent  of  the  policies  are  participating, 
i.  e.  the  policyholders  receive  dividends.  Again,  after  a  period  of  time 
the  policies  have  surrender  values;  many  discontinue  their  industrial 
insurance  and  take  out  ordinary  policies  and  the  surrender  values  are 
applied  to  them.  And,  finally,  as  in  connection  with  ordinary  policies, 
reserves  must  be  carried  to'  cover  the  higher  mortality  as  the  adult 
policyholders  increase  in  age.  While  the  business  is  rapidly  expanding 
the  amounts  added  to  reserve  must  be  substantial.  The  importance  of 
some  of  these  considerations  is  shown  by  data  for  the  three  largest  in- 
dustrial companies,  for  the  year  1916.  According  to  their  reports  to 
'  the  aSTew  York  Insurance  Department  the  three  companies  collected  in 
premiums  on  their  entire  industrial  business,  a  total  of  $151,367,823.57. 
The  death  claims  amoanted  to  $49,937,632.65  or  32.92  per  cent  of  this. 
The  amount  paid  out  in  "surrender  values^^  was  $2,578,295.54,  in  divi- 
dends paid  in  cash  or  applied  to  insurance  $14,651,022.81.  These  two 
sums  bring  the  total  returned  for  the  year  by  these  three  companies  to 
their  policyholders  up  to  $67,166,951,  or  44.37  per  cent  of  the  premiums. 
An  additional  and  substantial  allowance  must  be  made  for  necessary 
reserves.  And,  on  the  other  hand,  earnings  from  the  premiums  and 
invested  reserves  should  be  taken  into  consideration. 

Perhaps  the  fairest  comparison  made  of  what  industrial  policy- 
holders pay  and  what  they  in  return  receive  is  that  prepared  three  years 
ago  for  the  National  Convention  of  Insurance  Commissioners  by  its 
Committee  on  Social  (Welfare)  Insurance.^^  The  following  figures 
were  presented  for  the  three  largest  companies  from  the  date  of  beginning 
of  their  industrial  business  down  to  December  31,1915.  Total  premium 
receipts,  $1,811,843,770;  total  interest  income,  etc.,  $195,631,582;  total 
receipts,  $2,007,475,352;  total  payment  to  policyholders,  $713,477,427; 
total  funds  credited  to  policyholders,  $529,765,435;  total  payments  and 
credits  $1,243,242,862 ;  pereenta2:e  of  payments  and  credits  to  receipts, 
61.9. 

With  fair  comparisons,  it  may  be  said  that  not  far  from  two-fifths  of 
the  money  paid  by  policyholders  is  not  returned  to  them.  The  explan- 
ation of  this  fact  is  found  in  the  organization  required  for  the  conduct 
of  the  business  as  industrial  policies  have  been  written.  Agents  make 
the  rounds  of  the  homes  in  their  several  districts  writing  new  policies 
and  collecting  the  weekly  premiums;  for  the  three  largest  companies 
their  commissions  and  the  agency  and  supervisory  expenses  were  in  1916 
20.11  per  cent  of  the  premiums  collected.  Moreover,  a  complicated 
system  of  bookkeeping  is  required,  and  this,  auditing  and  the  other  de- 

20  The  Commission  is  indebted  to  Rufus  M.  Potts,  Chairman  of  the  Committee, 
for  the   privilege  of  making  use   of  this  manuscript  report. 


135 

tails  in  management,  for  the  three  largest  companies,  brought  the  entire 
expense  up  to  26.99  per  cent  of  the  premiums  collected. 

The  writing  of  industrial  life  insurance  on  individual  policies  is 
necessarih'  expensive.  At  one  time  it  and  health  insurance  were  com- 
bined, but  not  with  satisfactory  results.  Such  a  combination,  if  success- 
fully worked  out,  would  reduce  the  expense  of  management  and  make  the 
life  insurance  less  expensive.  At  present  attention  is  being  given  to  the 
development  of  group  life  insurance.  Whether  groups  were  written  by 
private  companies  or  under  a  state  controlled  system,  the  acquisition 
costs  would  be  very  much  reduced.  Group  insurance  is  discussed  in  the 
next  section  of  this  chapter.  It  should  be  said  at  this  point,  however, 
that  a  large  percentage  of  wage-earners  are  not  brought  together  in 
their  places  of  work  in  sufficiently  large  numbers  to  constitute  insurable 
groups.  It  should  be  added,  also,  that  under  any  system  of  insurance  of 
wage-earners  only,  many  persons  now  insured  would  find  no  place.  In- 
dustrial insurance  as  now  written  is  for  wage-earners  and  others,  in- 
cluding wives  and  children  not  gainfully  occupied.  Our  block  studies 
in  Chicago  show  a  larger  number  of  dependents  than  of  wage-earners 
carrying  this  form  of  insurance. 

(8)    Group  Insurance. 

Group  insurance,  as  it  is  written  to-day,  is  essentially  a  plan  for 
selling  insurance  at  wholesale  rates  to  an  employer  to  cover  the  risks  of 
his  employees.  For  the  most  part  it  is  a  cheaper  method  of  providing 
life  insurance  than  on  individual  policies.  Only  here  and  there  are 
group  health  and  accident  policies  being  sold.  However,  a  representative 
of  the  casualty  companies  has  stated  at  the  public  hearings  held  by  the 
Commission  that  group  health  and  accident  policies  give  a  very  desirable 
form  of  insurance  and  that  the  health  and  accident  hazards  of  60  per 
cent  of  the  wage-earners  can  be  covered  in  this  way  conveniently  and  at 
a  relatively  low  premium  cost.  Because  of  the  progress  it  is  making  in 
the  field  of  life  insurance  and  because  of  the  prospects  it  is  claimed  to 
hold  forth  in  the  field  of  health  and  accident  insurance,  group  insurance 
is  of  unusua.1  interest. 

Because  of  the  wide-spread  interest  in  and  claims  made  for  group 
insurance  the  Commission  has  made  as  extended  an  investigation  of  it 
as  the  circumstances  would  permit.  The  results  of  this  investigation 
are  set  forth  at  some  length  in  another  part  of  this  report.^^  At  this 
point  a  brief  summary  of  the  results  there  presented  will  suffice.  Group 
life  insurance  may  be  discussed  first,  and  then  a  short  statement  added 
concerning  the  comparatively  little  group  health  and  accident  insurance 
now  sold. 

Group  life  insurance. — Now  and  then  group  life  insurance  is  written 
on  individual  policies  for  the  employees  covered,  but  the  most  general 
practice  is  to  issue  it  on  a  "blanket"  policy  which  covers  the  lives  of  the 
members  of  the  group.  The  group  insured,  it  may  be  said,  may  be  of  the 
salaried  employees  only,  or  of  the  employees  of  a  certain  department  or 
of  certain  departments  only,  or  of  the  employees  of  all  departments  of 

"See  Part  II,  Special  Report  IX. 


136 


the  business.  It  is  written  after  a  census  or  list  of  the  employees  is 
prepared  giving  their  age,  sex,  etc.,  and  after  an  inspection  of  the  men, 
the  plant,  and  the  conditions  under  which  the  work  is  done.  Medical 
examination  of  the  employees  is  not  made,  but  only  such  exceptions  are 
permitted  of  men  in  a  group  of  employees  as  will  not  result  in  a  selection 
of  risks  adverse  to  the  insurance  company.  In  other  words,  only  such 
definite  factors  as  age  and  length  of  employment  may  be  used  in  making 
exceptions;  those  eligible  must  be  included  in  the  group  of  the  insured. 
•With  these  safeguards  and  with  a  minimum  of  50  or,  more  likely,  100 
the  group,  medical  examination  may  be  dispensed  with  without  a 


m 


4 


violation  of  actuarial  principles.  Occasionally,  it  is  true,  groups  of  less 
than  50  are  insured  but  in  such  cases  a  medical  examination,  usually  in 
modified  form,  is  made  of  each  of  the  men  accepted. 

The  policy  is  issued  to  the  employer  who  pays  the  premium  and 
assumes  the  responsibility  for  the  collection  of  any  part  of  the  cost 
charged  to  the  employees.  Benefit  certificates  are  generally  issued  to 
employees;  the  insurance  may  be  paid  directly  to  the  beneficiaries  named 
in  each  casC'  but  more  likely  payment  of  claims  is  made  through  the 
employer. 

Group  insurance  is  usually  term  insurance  and  most  frequently  takes 
the  form  of  a  one-year  renewable  policy.  The  policy  may  carry  a  guar- 
antee of  rates  for  a  period  of  years,  and,  like  individual  life  policies,  may 
be  participating  or  non-participating.  The  rates  are  based  upon  the  risk 
involved  in  the  given  case  and  the  premium  paid  is  the  sum  total  of  the 
rates  for  the  several  employees  on  the  list.  This  list  is  revised  with 
changes  in  the  personnel  of  the  working  force  and  adjustments  are  made 
periodically  in  the  premium,  the  amount  being  increased  or  decreased  as 
needed  in  view  of  changes  in  the  group  covered  by  the  "policy?  When  an 
employee  is  laid  off  his  insurance  may  or  may  not  be  continued  while  he 
is  not  on  the  pay-roll;  the  practice  varies.  When  he  is  discharged  or 
leaves  the  firm^s  employment,  however,  his  insurance  under  the  group 
policy  ceases.  But  in  this  connection  it  should  be  said  that  many,  and 
perhaps  a  majority  of  the  group  policies  in  force  contain  a  "conversion 
clause"  under  which  such  a  man  may  upon  application,  say  within  31 
days,   and  without  medical   examination,   obtain   an   individual   policy 

(but  usually  not  for  term  insurance),  at  the  rate  for  his  attained  age^ 

The  only  advantage  this  right  of  conversion  carries  with  it,  is  of  course 
that  it  eliminates  the  usual  medical  examination.  Because  it  saves  the 
"bother"  connected  with  this  and  enables  some  to  qualify  for  insurance 
who  could  not  pass  the  medical  examination^  the  right  is  sometimes  re- 
garded as  one  of  great  value.  As  a  matter  of  fact  the  opportunity 
offered  by  it  is  rarely  embraced,  for  one  reason  because  few  when  dis- 
charged or  leaving  a  place  of  employment  are  in  position  (at  just  that 
time)  to  add  to  the  insurance  they  carry  on  individual  policies.  It  is 
chiefly  those  who  leave  one  firm  to  accept  employment  at  good  wages 
with  another  for  whom  it  has  value. 

This  is  a  brief,  and  because  brief  necessarily  an  inadequate,  descrip- 
tion of  group  life  insurance.  From  an  insurance  point  of  view  it  seems 
to  be  written  with  proper  regard  for  good  insurance  principles.     The 


137 

writing  of  such  policies  has  been  authorized  in  most  states,  with  mini- 
mum groups  of  50  or  100. 

Though  older  instances  are  placed  in  evidence,  from  a  practical 
point  of  view  group  life  insurance  is  a  new  device.  It  is  commonly  said 
to  date  from  1912  when  a  group  policy  was  issued  to  a  prominent  Illi- 
nois mercantile  firm.  During  the  last  five  years  it  has  made  rapid 
progress  in  the  United  States.  According  to  the  Actuaiy  of  the  Con- 
necticut Insurance  Department,  the  number  of  men  thus  insured  in  this 
country  Increased  from  11,450  December  31,  1912,  to  105,000  on  the 
corresponding  date  in  1915,  and  to  325,000  June  30,  1917.  The  amount 
of  insurance  in  force  was  $13,083,000,  $83,920,000,  and  $250,000,000 
for  these  three  dates.  Most  of  this  insurance  has  been  written  by  five 
companies;  it  is  only  recently  that  any  considerable  number  of  com- 
panies have  undertaken  to  write  insurance  in  this  form.  The  five  prin- 
cipal companies  have  reported  to  the  Commission  with  reference  to  their 
policies  in  Illinois.  Beginning  with  2  in  1912,  they  had  31  in  force 
December  31,  1916,  and  66  December  31,  1917.  For  the  second  date 
the  number  of  employees  covered  was  3,129,  the  amount  of  insurance, 
$2,809,676;  for  the  last  date  the  number  of  employees  covered  was 
24,877,  the  amount  of  insurance,  $20,092,851.^^  The  amount  of  group 
life  insurance  written  in  Illinois  previous  to  1918  by  other  companies 
was  negligible.  It  is  evident  therefore  that  it  is  only  recently,  during 
an  abnormal  state  of  the  labor  market  and  at  a  time  marked  by  the  spirit 
of  cooperation,  that  much  interest  has  been  manifested  in  group  in- 
surance, and  that  the  most  recent  data  available,  though  they  indicate 
marked  progress,  show  that  the  amount  written  is  still  small  as  compared 
to  insurance  written  on  industrial  or  other  individual  policies. 

Group  life  insurance  is  sold  to  the  employer,  not  to  his  employees. 
Moreover,  while  the  employees  have  elsewhere  not  infrequently  paid  a 
share  of  the  premium,  the  reports  from  five  companies  referred  to  above 
indicate  that  under  all  of  the  contracts  written  by  them  in  Illinois  in  1917 
the  entire  premium  was  paid  by  the  employer.  Detailed  statements 
received  from  twenty-four  employers  carrying  group  policies  were  to 
the  effect  that  no  part  of  the  premiums  was  collected  from  the  employees. 

It  is  safe  to  assume,  therefore,  that  there  are  few,  if  any,  establish- 
ments in  Illinois  where  employees  contribute  money  to  the  payment  of 
premiums  on  group  life  insurance.  The  employers  assume  the  entire 
burden  because  the  premium  usually  amounts  to  only  $1  or  less  per 
month  per  man,  because  any  division  of  the  cost  is  likely  to  provoke 
trouble  whether  the  participation  in  the  plan  is  optional  or  compulsory 
on  the  part  of  the  employees,  and  because  any  division  of  the  cost  is 
likely  to  defeat  one  of  the  ends  in  view — expression  of  appreciation  by  the 
employer  and  the  development  of  industrial  good-will. 

Correspondence  and  conferences  with  employers  carrying  group 
policies  and  with  others  who  have  it  under  consideration  (and  a  very 
considerable  number  are  studying  it  carefully)  indicate  that  they  as  a 
group  have  at  least  a  three-fold  interest  in  this  insurance.     All  are  found 

23  According  to  an  official  of  The  Travelers  Insurance  Company  the  number 
of  employees  now  (March  1,  1919),  covered  by  group  policies  is  approximately 
75,000,  or  three  times  the  number  December  31,  1917. 


138 

in  other  welfare  plans.  One  of  these,  and  very  important,  is  the  humani- 
tarian interest  which  causes  them  to  desire  that  the  employee's  dependents 
shall  be  provided  for  in  the  event  of  his  death.  The  employers  appre- 
ciate, as  every  one  must,  the  value  of  life  insurance;  they  feel  that  too 
little  is  being  carried ;  they  know  that  many  of  their  employees  have  no 
insurance  or  only  the  usual  industrial  or  fraternal  policy ;  they  may  feel 
that  their  employees  cannot  well  afford  to  carry  a  desirable  amount  of 
insurance  in  view  of  the  more  immediate  demands  upon  their  incomes. 
Again,  they  may  feel  that  they  "owe"  their  employees,  or  a  part  of  them, 
something  more  than  wages  paid  at  the  current  rate.  This  is  a  way  of 
meeting  the  obligation  felt  in  a  manner  appreciated  by  the  employees. 
Another  motive  is  to  develop  good  will  on  the  part  of  their  employees,  to 
attract  a  better  class  of  applicants  for  w^ork,  and,  more  especially,  to 
retain  desirable  men  in  their  employment  and  thus  reduce  the  turnover 
of  labor  which  involves  considerable  direct  and  indirect  expense.  Many 
hope  that  it  will  be  worth  more  than  it  costs.  It  is  altogether  possible 
that,  looking  on  beyond,  they  hope  group  insurance,  as  well  as  other  wel- 
fare plans  which  may  be  combined  with  it,  will  assist  both  in  preventing 
an  organization  of  labor  with  its  demands  for  higher  wages  and  shorter v 
hours,  and  in  handling  strikes.  No  evidence  of  the  presence  of  any 
such  desire  has  been  secured.  It  may  not  be  out  of  point  to  state,  how- 
ever, that  the  employers  showing  interest  in  group  insurance  and  other 
welfare  plans,  with  few  exceptions,  conduct  "open  shop"  establishments. 
But,  it  must  be  added,  union  men  look  with  suspicion  upon  most  if  not 
all  welfare  plans,  so  that  their  employers  would  naturally  be  less  interested 
than  others  in  group  insurance. 

As  stated,  many  employers  hope  that  group  insurance  will  pay  for 
itself.  The  cost  varies  not  only  w^th  age,  race,  working  conditions  and 
the  like,  but  also  with  the  amount  of  insurance  per  employee.  The  raies 
quoted  vary  between  less  than  one  per  cent  net  to  about  one  and  a 
quarter  per  cent  of  the  pay-roll  w^hen  the  amount  of  insurance  is  one 
year's  wages,  but  most  frequently,  it  is  near  one  per  cent.  It  would 
appear,  however,  that  there  are  variations  from  the  rates  usually  quoted 
because  with  group  insurance  being  actively  "pushed"  the  competition 
in  respect  to  rates  as  well  as  in  respect  to  the  terms  of  the  policy  is  very 
keen.  In  any  event  the  premium  is  considerably  smaller  than  on  in- 
dividual policies  for  the  cost  of  acquisition,  accounting  and  management 
are  very  much  reduced.  The  men  are  insured  wholesale;  it  is  not 
necessary  to  visit  prospects  in  their  homes  or  elsewhere.  Moreover,  the 
insurance  is  usually  sold  by  the  main  office,  not  through  a  local  agent 
who  must  have  a  commission.  High  officials  in  one  of  the  leading  com- 
panies have  stated  that  it  costs  from  7  to  10  per  cent  of  the  premium  to 
write  a  group  policy  as  against  35  or  more  to  write  individual  industrial 
policies.  In  this  connection  it  must,  of  course,  be  held  in  mind  that 
the  amount  of  insurance  per  man  is  less  on  industrial  than  under  the 
group  policies. 

The  group  insurance  policies  issued  in  Illinois  have  been  shaped  by 
the  ends  employers  have  in  view.  In  some  cases,  as  has  been  stated 
above,  only  salaried  employees  are  insured;  those  newly  added  to  the 


139 

pay-roll  are  generally  excluded  and  in  some  cases  only  those  who  have 
been  employed  for  three  months,  or  six  months,  or  a  year  are  placed  on 
the  insured  list.  In  about  three  cases  in  four  where  the  details  of 
policies  are  known,  the  amount  of  insurance  increases  with  the  period  of 
service.  This  is  because  such  men  are  regarded  as  more  valuable  to  the 
film  or  it  is  felt  that  the  firm  "owes  them  more."  The  amount  of 
insurance  is  usually  a  substantial  sum,  as  tested  by  the  amounts  wage- 
earners  carry.  The  average  per  man  of  the  insurance  in  effect  in  Illinois 
December  31,  1917,  though  most  of  it  had  recently  been  issued,  was  a 
little  more  than  $800.  It  may  begin  at  $150,  $250,  or  $300  or,  more 
likely,  $500,  and  in  some  cases  it  begins  at  $1,000.  Additions  with 
period  of  service  may  double  or  treble  the  amount  in  the  course  of  six 
or  seven  years.  Less  frequently  it  is  a  flat  and  invariable  sum,  say  $500 
or  $1,000,  per  man.  Or  it  may  be,  and  not  infrequently  is,  a  year's 
wages,  with  or  without  a  maximum  operative  only  in  the  case  of  high- 
salaried  employees. 

It  goes  without  saying  that  life  insurance,  averaging,  perhaps,  one 
j^ear's  wages,  is  distinctly  worth  the  while  to  the  beneficiaries.  It  pays 
the  cost  of  the  last  sickness  and  burial  and  usually  leaves  a  substantial 
sum  to  cover  the  period  of  necessary  readjustment.  Nevertheless,  group 
insurance  has  met  with  strong  opposition,  not  only  from  insurance  com- 
missioners and  many  insurance  companies  who  in  the  past  have  been 
doubtful  of  the  wisdom  of  eliminating  medical  examination  in  any  case, 
but  also  from  others.  The  fraternal  orders  have  shown  considerable 
opposition  to  it,  no  doubt  in  part  because  it  competes  with  their  own 
insurance.  One  of  their  representatives  has  said  at  the  Commission's 
hearings  that  it  frequently  causes  the  workmen  to  cancel  other  insurance 
they  carry  or  to  fail  to  "take  out"  the  insurance  they  otherwise  would; 
and  then  to  find  themselves  without  needed  insurance  when  discharged 
or  quitting,  when  perhaps  they  cannot  pass  the  necessary  medical  examin- 
ation or  have  become  too  old  to  secure  insurance  on  acceptable  terms. 
It  was  asserted,  moreover,  that  the  cost,  and  more,  was  after  all  borne 
by  the  workmen  in  the  lower  wages  they  receive.  xA.nd,  again,  it  was 
pointed  out  that  the  employer  may  discontinue  the  insurance  at  will. 

Organized  labor  is  opposed  to  group  insurance  and  for  the  same 
reasons  that  it  is  opposed  to  employers'  welfare  plans  in  general.  In 
addition  to  such  objections  as  those  mentioned  above  it  is  asserted  that 
it  "ties  a  man  to  the  job"  and  is  aimed  or  tends  to  prevent  the  organi- 
zation of  labor  or  to  weaken  it  and  defeat  its  economic  ends — higher 
wages,  shorter  hours  and  better  working  conditions.  And,  again,  it  is 
said  that  it  will  place  a  premium  on  the  physical  examination  of  workmen 
and  the  rejection  or  possibly  the  discharge  of  the  less  desirable  risks 
among  them  so  as  to  keep  the  premium  down  to  a  minimum. 

The  time  has  not  come  to  pass  judgment  upon  group  life  insurance 
in  the  light  of  evidence  furnished  by  experience.  The  experience  has 
been  brief  and  limited  practically  to  a  period  marked  by  a  labor  shortage 
and  by  rising  wages  even  in  the  absence  of  organization.  Most  employers 
who  have  experimented  with  it  are  unable  to  say  how  much  effect  it 
should  have  on  the  turnover  of  labor  and  the  development  of  good  will 


140 

on  the  part  of  their  employees.  There  can  be  no  doubt  that  it  has  been 
provided  in  addition  to  wages  as  currently  paid.  Whether  it  would 
prove  to  be  a  substitute  for  higher  wages  and  better  conditions  in  the 
long  run  and  if  more  general  cannot  be  answered  in  the  light  of  estab- 
lished fact. 

Group  hmlth  and  accident  inswrancp,. — "Group  health  and  accident 
insurance"  is  a  new  name  for  what  was  formerly  called  "workmen's 
collective  insurance."  Under  the  older  name  it  dates  back  perhaps 
thirty  years  in  the  United  States  and  to  1882  in  England.  In  the  older 
practice  a  "blanket"  policy  was  issued  to  an  employer  covering  only 
occupational  or  occupational  and  non-occupational  accidents  to  his  em- 
ployees. This  kind  of  insurance  made  little  headway  in  this  country 
because  of  union  opposition,  the  comparatively  high  premiums  charged 
for  it,  and  the  enactment  of  workmen's  compensation  laws  before  it 
became  well  known./  In  Illinois  little  of  it  seems  to  have  been  written, 
but  a  few  thousand  dollars  is  still  collected  each  year  a?  premiums  on 
policies  bearing  that  name.  Perhaps  the  Aetna  Company  was  one  of 
the  first  to  write  health  insurance  on  the  group  plan  for  as  early  as 
1898  it  was  issuing  combined  health  and  accident  contracts  under  the 
old  name. 

Though  originating  20  years  or  more  ago  and  though  its  merits  are 
urged  upon  the  attention  of  those  who  may  be  interested,  group  health 
and  accident  insurance  is  written  in  the  United  States  neither  extensively 
nor  in  a  standardized  form.  A  well-informed  insurance  man  special- 
izing in  this  branch  of  insurance  states  in  a  letter  to  the  Commission 
that  perhaps  not  more  than  $500,000  a  year  is  collected  in  premiums  on 
the  group  insurance  (under  the  new  name)  in  force.  Three  of  the  six 
companies  reporting  to  the  Commission  that  they  wrote  group  life  in- 
surance in  Illinois,  stated  that  they  also  issue  group  health  and  accident 
policies  but  only  one  of  these  had  (in  1918)  issued  any  in  this  State. 
In  addition  to  these  companies,  a  number  of  casualty  companies  are 
prepared  to  write  such  policies,  but  some  of  them  still  have  their  first 
policy  to  write.  yMost  of  the  contracts  are  written  on  forms  specially 
drawn,  not  on  standard  forms  in  general  use.  Group  health  and  accident 
insurance  is  still  in  the  experimental  stage,  and  among  insurance  men 
will  be  found  those  who  have  doubt  as  to  its  eventual  success^  They 
fear  that  the  problem  of  simulation  and  malingering  will  be  difficult 
to  meet,     y 

Inasmuch  as  so-called  standard  forms  developed  are  not  widely  used, 
it  is  difficult  to  describe  group  health  and  accident  insurance  accurately. 
From  the  data  available,  however,  it  may  be  said  to  incorporate  pretty 
much  the  same  standards  as  the  individual  policies  issued  by  casualty 
companies.  The  policy  will  cover  certain  risks,  perhaps  with  a  7  day 
waiting  period  and  a  26  weeks  or  a  52  weeks  maximum  in  the  given  case. 
It  may  be  said,  also,  that  being  shaped  pretty  much  by  the  wishes  of  the 
employer,  its  provisions  are  similar  to  those  developed  for  establishment 
funds  organized  by  the  employer.  The  weekly  benefit  may  be*a  fraction 
of  wages,  most  likely  fifty  per  cent,  or  it  may  be  a  lump  sum.  Provision 
may  or  may  not  be  made  for  medical  attention. 


141 

Obviously  it  is  impossible  to  state  what  percentage  the  premium  foi- 
group  health  and  accident  insurance  is  of  the  pay-roll.  It  varies  with 
the  hazard  and.  the  provisions  incorporated  in  the  contract.  This  in- 
surance is,  however,  considerably  cheaper  than  that  written  on  individual 
policies.  The  accounting  and  collection  expense  is  reduced,  and  instead 
of  the  large  commission  paid  agents  as  set  forth  above  the  commissions 
being  paid  vary  from  7  to  10  per  cent  of  the  premiums.  Obviously  with 
equally  good  administration  the  cost  would  be  somewhat  larger  than  the 
cost  under  an  establishment  fund  arrangement  making  the  same  provision 
in  benefits.  The  cost  of  this  insurance  may  be  paid  by  the  employer,  or 
by  the  employees,  or  be  divided  between  them. 

The  advantages  of  health  and  accident  insurance  are  great.  When 
written  on  these  group  policies  it  is  open  to  much  the  same  criticism  as 
group  life  insurance  except  that  the  tendency  "to  tie  the  employee  to  his 
'  job"  is  not  so  strong.  Perhaps  all  that  needs  to  be  said  is  that  it  amounts 
to  an  establishment  fund  arrangement  with  an  outside  carrier  and  with 
this  carrier  and  the  employer,  with  little  expression  of  preference  on  the 
part  of  the  insured,  determining  the  standards  which  shall  be  incor- 
porated in  the  contract.  Possibly  the  question  should  be  raised  as  to 
what  it  offers  besides  the  assumption  of  the  risk  under  the  contract  and 
the  advertising  by  the  carrier  that  will  induce  employers  to  make  use 
of  it  rather  than  develop  establishment  funds.  It  does,  however,  com- 
bine the  risks  for  the  several  firms  for  which  contracts  are  written, 
it  advertises  health  insurance,  and  provides  a  method  of  insurance  for 
groups  of  sufficient  size,  i.  e.  50,  the  minimum  usually  accepted. 

(9)   Insurance  as  Found  Among  Wage-earners  in  Chicago. 

In  addition  to  that  secured  from  establishment  funds,  unions, 
fraternal  orders,  foreign  societies,  and  insurance  companies  of  various 
kinds,  the  Commission  secured  information  relating  to  insurance  from 
the  families  selected  for  study  in  Chicago.  Of  course  the  insurance 
situation  differs  greatly  from  one  locality  to  another;  hence  the  data 
secured  in  Chicago  cannot  be  accepted  as  representative  in  all  respects, 
but  chiefl}^  in  respect  to  the  number  of  w^age-earners  who  are  insured 
against  loss  of  income  due  to  disabling  sickness.  In  most  respects  the 
data  are  probably  fairly  representative  and  are  of  value  in  indicating 
certain  things  not  brought  out  in  the  above  summary. 

First  of  all  it  should  be  said  that  in  some  cases  the  informant,  most 
frequently  the  wife,  did  not  know  whether  or  not  the  husband  had  dis- 
ability insurance  especially  if  it  was  provided  by  the  establishment  in 
which  he  was  emplo3^ed.  Moreover,  in  a  considerable  number  of  cases 
the  informant's  knowledge  of  insurance  carried  did  not  extend  to  the  rate 
of  benefit  per  week.  Where  there  had  been  sickness,  however,  the  in- 
formation desired  was  usually  obtained  fully  and  accurately.  The 
following  summary  of  details  relating  to  disability  insurance  must  be 
used  with  the  limitations  indicated. 

The  families  studied  in  the  blocks  selected  as  typical  in  Chicago 
contained  4,801  members  who  were  gainfully  occupied  and  for  whom 
desired  information  was  obtained — 4,456  as  wage-earners  and  345  on 


142 

their  own  account.  Of  the  wage-earners  1,055  or  23,7  per  cent  were 
found  to  be  insured  against  sickness  or  against  sickness  and  accident. 
The  corresponding  figure  for  the  smaller  number  working  on  their  own 
account  was  89  or  25.8  per  cent.  Of  the  1,055  wage-earners  insured,  978 
reported  1,126  policies  (or  membership  rights),  for  a  considerable  num- 
ber were  insured  in  two,  and  a  few  in  three  organizations.  Of  the  1,055, 
107  were  insured  for  less  than  $5  per  week;  688,  for  $5  but  less  than 
$10  (usually  $5  or  $7)  ;  138,  for  $10  but  less  than  $15  (most  frequently 
$10)  ;  and  45,  for  $15  or  over. 

Fairly  complete  information  was  secured  where  a  wage-earner  had 
been  sick.     The  following  table  shows  a  number  of  significant  things. 


Economic  status. 


Number 
of  wage- 
earners. 


Number 
losing 

wages  for 

more  than 

1  week. 


Per  cent 
wage- 
earners 
losing 
wages. 


Number 
paid  sick 
benefits. 


Per  cent 

of 
sick  paid 
benefits. 


Average 
wage  loss 
per  man. 


Average 

benefit 

received. 


Per  cent 

of 
benefit  of 
wage  loss. 


A 

2,770 
937 
373 

4,474 

563 
223 
108 
937 

24.8 
23.8 
29.0 
20.9 

89 

27 

8 

126 

15.8 

12.1 

7.4 

13.4 

$119.  35 
101.  93 
141.  64 
118.  76 

$56.60 
43.96 
22.00 
52.44 

47.4 

B 

43.1 

C 

15.5 

All* 

44.1 

*  Includes   wagre-earners   in  addition   to  these  classed  "A,"  "B"  and  "C." 

The  significant  facts  shown  by  this  table  are: 

(1)  That  20.9  per, cent  of  the  4,474  wage-earners  lost  wages  for 
more  than  one  week  in  the  course  of  the  year^  and  that  only  13.4  per  cent 
of  these  received  sick  benefits ; 

(2)  That  the  average  wage  loss  was  $118.76,  and  that  the  average 
benefit  received  was  $52.44  or  44.1  per  cent  of  the  amount  lost; 

(3)  That,  taking  the  group  as  a  whole,  the  disability  insurance  re- 
ceived was  less  than  6  per  cent  of  the  wages  lost  because  of  disabilities 
lasting  more  than  a  week; 

(4)  That  the  wage-earners  in  Class  "C"  (in  the  poverty  class),  less 
able  to  bear  the  financial  loss  connected  with  disabling  sickness  than 
those  in  Class  B  (with  meager  incomes)  and  in  Class  A  (with  moderate 
incomes),  experienced  the  greatest  amount  of  sickness  and  sustained  the 
largest  average  loss  of  wages ;  and 

(5)  That,  as  has  been  frequently  stated,  those  in  the  most  insecure 
economic  position  had  the  smallest  number  insured  and  received  in 
benefits  the  smallest  percentage  of  wages  lost. 

Of  course  the  number  of  wage-earners  included  in  the  study  is  small. 
Yet  they  tend  to  confirm  the  conclusion  that  those  most  in  need  of  dis- 
ability insurance  are  least  well  provided  with  it. 

In  the  table  presented  above  all  wage-earners  in  the  families  studied 
are  included.  In  the  table  following  data  are  presented  for  wage-earning 
husbands  charged  with  family  responsibilities,  these  being  grouped  by 
"economic  status" — those  with  moderate  incomes  (A),  those  with  meager 
incomes  (B),  and  those  with  poverty  incomes (C). 


143 


Economic  status  of  husbands. 


Number. 


Number 
insured. 


Per  cent 

insured. 


Number 
reporting 
amount  of 
insurance. 


Average 
amount  of 
insurance 
per  week. 


A... 
B... 
C... 

All* 


1,475 

565 

38.3 

517 

559 

219 

39.2 

212 

215 

52 

24.2 

50 

2,315 

850 

36.7 

788 

$7.37 
6.46 
5.58 
6.98 


*  Includes  66  husbands  not  classed  as  A,  B  or  C. 

This  table  shows  the  following  significant  facts: 

(1)  That  while  the  relative  number  of  these  "main  bread-winners" 
insured  was  larger  than  that  of  all  wage-earners  (23.7  per  cent  as  shown 
above),  only  36.7  per  cent  had  health  insurance; 

(2)  That  the  heads  of  families  with  smallest  incomes  as  compared 
to  needs,  whose  incomes  could  least  well  be  sacrificed,  were  least  fre- 
quently insured;  and 

(3)  That  the  average  benefit  (from  one  or  more  policies)  was  a 
little  less  than  $7.00  per  week,  which  is  not  more  than  a  third  of  their 
wages  as  shown  by  the  fact  that  2,203  of  them  earned  $2,226,904  or  an 
average  of  $1,010. 8-5  each  during  the  year  in  spite  of  considerable  lost 
time. 

Turning  to  life  insurance  and  funeral  benefits,  it  was  found  that 
7,193  or  57.8  per  cent  of  the  persons  in  the  wage-earning  and  non-wage- 
earning  families  studied  were  insured  in  larger  or  smaller  sums,  the  aver- 
age value  of  the  7,721  policies  being  $419.24.  Of  husbands,  74.8  were  in- 
sured; of  wives  58.8  per  cent;  of  males  over  14,  other  than  husbands,  56.5 
per  cent;  of  females  over  14,  other  than  wives,  53.6  per  cent;  of  children 
under  14,  48.8  per  cent.  The  average  values  of  the  policies  were  $758, 
$474,  $423,  $307,  and  $101  for  the  five  groups  respectively. 

Noteworthy  differences  were  found  among  the  several  nationalities, 
but  one  or  more  members  in  a  majority  of  families  had  life  insurance. 
The  smallest  percentage  (57.8)  of  families  with  one  or  more  mem- 
bers insured  w^as  found  among  the  Italians;  the  largest  (93.8)  among 
the  colored.  There  were  marked  differences,  also,  in  the  value  of 
policies  carried  by  the  members  of  the  several  races.  More  important, 
however,  was  the  relation  found  betw^een  "economic  status"  and  the 
amount  of  life  insurance  carried.  As  with  disability  insurance,  so  with 
life  insurance  was  it  found  that  the  largest  number  of  families  without 
insurance  and  the  smallest  policies  were  among  those  with  smallest  in- 
comes as  compared  to  needs.  Of  the  "A"  families,  one  or  more  members 
of  84.5  per  cent  of  the  total  number  had  insurance ;  of  the  "B"  families, 
85.1  per  cent;  of  the  "C"  families,  73.2  per  cent.  Taking  the  total 
number  of  members  in  the  families  grouped  into  the  three  classes,  60.8 
per  cent  of  the  first  (A),  60.1  per  cent  of  the  second  (B),  and  50.7  per 
cent  of  the  third  (C)  were  insured.  The  average  number  of  policies 
per  policyholder  in  the  first  class  was  1.08,  in  the  second  1.05,  and  in 
the  third  1.04.  Taking  the  average  values  of  the  policies  for  three 
classes,  they  are  found  to  be  $467.34,  $319.12  and  $288.74,  respectively. 
This  means  that  the  average  amount  of  insurance  per  policyholder  was 
approximately  $505  in  Class  A,  $335  in  Class  B,  and  $300  in  Class  C. 


144 

The  life  insurance  carried  by  male  heads  of  wage-earning  families 
is  of  special  interest.  Of  a  total  of  2,417,  1,865  or  77.2  per  cent  were 
insured.  The  total  number  of  policies  carried  was  2,167;  the  value  of 
1,908  of  these  was  $1,396,673  or  an  average  of  $732  each.  In  other 
words,  77.2  per  cent  of  the  male  heads  of  families  were  insured  for  an 
average  of  approximately  $850. 

Here,  again,  noteworthy  contrasts  were  found  as  between  the  three 
economic  groups.  Of  the  male  heads  of  1,220  families  with  moderate 
incomes,  78.8  were  insured  for  an  average  of  approximately  $854  each; 
of  the  male  heads  of  436  with  meager  incomes,  76.2  per  cent,  for  an 
average  of  $765;  of  the  male  heads  of  147  families  with  poverty  in- 
comes, 68.4  per  cent,  for  an  average  of  $742. 

The  number  of  policies  and  amount  of  insurance  in  insurance  organ- 
izations of  different  kinds  has  been  tabulated  for  male  heads  of  wage- 
earning  families  only.  The  number  of  "ordinary  policies"  was  206,  the 
amount  $269,700;  of  "industrial  policies,"  578,  the  amount  $286,605;  of 
fraternal  policies,  952,  the  amount  $743,819 ;  of  union  membership  cer- 
tificates, 115,  the  amount  $69,048;  of  other  policies  (in  foreign  benefit 
societies,  etc.),  57,  the  amount  $27,501.  Thus  almost  half  of  the  policies 
reported  (952  of  1,908)  and  more  than  half  of  the  insurance  ($743,819 
of  $1,386,673)  were  in  fraternal  orders.  This  is  not  true  of  other 
members  of  these  families.  Nearly  all  of  the  insurance  of  children,  for 
example,  is  "industrial." 

(10)   The  Existing  Health  Insurance  Summarized. 

The  summaries  of  the  insurance  activities  of  organizations  of  several 
different  kinds  presented  above  are  designed  to  show  the  existing  in- 
surance situation  among  wage-earners  and  their  families  in  Illinois. 
Because  they  are  summaries  some  needed  qualifications  and  explanations 
may  have  been  omitted.  As  stated  above,  more  complete  and  more  ade- 
quate reports  on  establishment  funds,  union  benefit  systems,  insurance 
by  fraternal  organizations,  provision  made  by  foreign  benefit  societies,  in- 
surance by  casualty  companies  and  assessment  associations,  industrial  in- 
surance, and  group  life  and  disability  insurance  will  be  found  in  special 
studies  printed  in  Part  II  of  this  report.  ^^ 

In  concluding  this  summary  of  facts  the  existing  insurance  situation 
may  be  stated  in  the  fewest  words.  This  may  be  prefaced  by  the  remark 
that  the  number  and  greatest  variety  of  existing  institutions  providing 
sickness  and  accident  benefits  and  life  insurance  and  funeral  bene- 
fits evidence  an  appreciation  of  the  problems  connected  with  sickness, 
accident,  and  death,  and  the  applicability  of  the  principle  of  insurance 
to  them  in  partially  indemnifying  the  losses  sustained. 

Our  investigations  show,  first  of  all,  that  the  majority  of  wage- 
earners,  and  especially  of  those  who  are  heads  of  families,  are  provided 
with  life  insurance  or  with  funeral  benefits.  More  than  three-quarters 
of  the  male  heads  of  wage-earning  families  studied  in  Chicago  had  such 

2«  Inasmuch  as  the  provision  made  for  many  public  employees  through  existing 
pension  funds  has  been  under  investigation  by  the  Pension  Laws  Commission,  no 
investigation  of  it  was  made  by  this  Commission  and  only  incidental  reference  is 
made  to  it  in  this  report.  For  the  results  of  this  investigation  made  by  the  Pension 
Laws  Commission  see  its  forthcoming  report. 


145 

provision,  and  there  is  reason  to  believe  that  these  wage-earners  are 
fairly  typical  of  those  of  the  State  as  a  whole.  Dependent  members  of 
Rvage-earning  families  are  only  less  extensively  insured  for  smaller 
amounts. 

Much  of  the  life  insurance  carried  by  wage-earners,  and  especially 
by  heads  of  families,  is  sufficient  not  only  to  cover  funeral  costs  and  the 
expenses  of  last  illness,  but  also  to  leave  something  to  defray  necessary 
family  expenses  during  the  period  of  readjustment  after  the  bread- 
winner's death.  This  is  true  of  most  of  the  life  insurance  provided  by 
the  fraternal  orders  (the  greatest  carriers)  ;  of  nearly  all  of  the  group 
insurance  being  provided  by  rapidly  increasing,  but  not  as  yet  large, 
number  of  employers;  of  some  of  that  provided  by  employers  as  a  part 
of  their  welfare  plans;  and  of  a  small  part  of  the  union  insurance.' 
^loreover,  it  would  appear  that  a  considerable  percentage  of  the  heads  of 
families  have  ordinary  life  insurance  policies  with  life  insurance  com-- 
panics.  On  the  other  hand,  most  of  the  insurance  provided  by  unions, 
by  establishment  funds,  by  "foreign  societies,"  and  by  companies  writing 
industrial  insurance,  and  a  considerable  part  of  that  provided  by  frater- 
nal societies  is  intended  to  serve  as  a  funeral  benefit  and,  perhaps,  to 
cover  a  part  or  all  of  the  expenses  incidental  to  the  last  illness. 

If  we  may  asume  the  need  of  at  least  enough  insurance  to  con- 
stitute a  funeral  benefit,  the  first  defect  in  the  existing  insurance  lies 
in  the  fact  that  a  considerable  number  of  wage-earners  have  none.  The 
carrying  of  insurance  being  voluntary  with  comparatively  few  exceptions, 
some  have  not  sought  it;  a  smaller  number  have  not  been  able  to  secure 
it,  for,  naturally  enough,  the  carriers,  with  few  exceptions,  select  their, 
risks;  others  because  of  financial  strain  or  for  other  reason  have  per- 
mitted their  insurance  to  lapse  by  non-payment  of  premiums  or  by  the 
discontinuance  of  membership  in  an  organization  providing  insurance 
for  its  members.  Directly  connected  with  this  last  consideration,  it 
should  be  noted  that  almost  always  group  insurance  and  that  provided 
by  establishment  funds  and  by  employers  as  a  part  of  their  welfare  plans 
ceases  with  discontinuance  of  employment  with  the  given  firm  or  in  the 
establishment.  There  is,  as  would  be  expected,  more  or  less  criticism  of 
such  insurance  on  the  ground  that  "it  ties  a  man  to  his  job.'' 

Most  of  the  insurance  and  funeral  benefits  are  provided  by  mutual 
organizations.  Only  the  industrial  insurance  wTitten  on  individual 
policies,  very  extensively  employed  to  cover  funeral  costs,  especially  in 
the  case  of  women  and  children,  is  criticized  on  the  ground  that  it  is 
relatively  expensive.  The  premiums  on  industrial  insurance  (on  in- 
dividual policies)  are  necessarily  high  because  of  the  high  cost  of 
placing  the  insurance  and  of  making  the  weekly  collections.  Because  of 
these  expenses  the  total  of  payments  and  sums  credited  to  the  policy- 
holders of  the  three  largest  companies  writing  industrial  insurance  had 
been  only  61.9  per  cent  of  the  premiums  collected  and  the  income  secured 
from  the  funds  invested,  from  the  beginning  of  business  to  December  31, 
1915.  Finally,  whether  or  not  it  is  to  be  regarded  as  a  defect,  it  may 
be  pointed  out  that  with  the  exception  of  group  insurance,  that  provided 

—10  H  I 


146 


by  employers,  and  some  of  that  provided  by  establishment  funds — a  com- 
paratively small  part  of  the  whole — the  entire  cost  of  the  insurance 
carried  is  borne  by  the  insured.- 

Among  wage-earners,  sickness  or  health  insurance,  though  more  and 
more  extensively  prpvided,  is  much  less  frequently  found  than  life  in- 
surance and  funeral  benefits.  As  against  all  manual  wage-earners  and 
all  other  employed  persons  earning  less  than  160  pounds  per  year  in 
Great  Britain  and  nearly  all  wage-earners  in  Germany  provided  with 
sickness  insurance  under  the  compulsory  laws  in  effect,  perhaps  30  per 
cent  of  the  wage-earners  in  Illinois  have  such  insurance  on  a  voluntary 
basis  with  one  or  more  organizations  of  some  kind  or  other.  Important 
among  these  organizations  are  fraternal  benefit  societies,  the  casualty 
companies  and  assessment  associations,  unions,  establishment  funds,  and 
foreign  benefit  societies. 

The  estimate  that  "perhaps  30  per  cent  of  the  wage-earners  of  Illi- 
nois" have  insurance  against  disabling  sickness  is  a  rough  one.  The 
possible  errors  entering  into  the  making  of  any  estimate  are  numerous. 
In  the  first  place,  it  is  possible  to  estimate  the  number  of  wage-earners 
only  approximately — at  1,850,000.  In  the  second  place  and  more  im- 
portant, the  possible  error  in  the  estimated  number  of  the  wage-earning 
group  insured  through  organizations  of  different  kinds  is  large.  Be- 
cause of  the  interstate  employment  of  railway  and  certain  other  em- 
ployees, several  incomplete  reports,  and  a  number  of  funds  not  studied, 
the  estimated  number  insured  through  establishment  funds  must  be  set 
down  as  between  the  wide  limits  of  97,500  and  130,000.  The  number 
insured  through  union  funds  can  be  estimated  more  accurately  at  between 
135,000  and  145,000.  Estimates  of  from  250,000  to  300^000  and  of 
35,000  for  fraternal  benefit  societies  and  independent  foreign  societies 
respectively  are  roughly  made.  The  estimate  of  100,000  for  casualty 
companies  and  40,000  for  assessment  companies  are  "outside  figures.^' 
No  estimate  is  ventured  as  to  the  number  insured  in  church  clubs  for 
these  were  not  studied  except  in  the  most  incidental  way.  A  further 
source  of  difficulty  is  found  in  the  fact  that  a  considerable  number  of 
the  members  of  wage-earning  families  insured,  except  in  establishment 
and  union  funds,  are  not  themselves  wage-earners  but  dependent  wives 
or  others.  Perhaps  any  total  arrived  at  by  adding  the  number  of  insured 
through  organizations  of  different  kinds  would  have  to  be  reduced  by 
50,000  because  of  this  fact.  And,  finally,  a  further  reduction  would 
have  to  be  made  because  some  wage-earners  are  insured  in  two  or  more 
organizations.  Just  how  large  a  reduction  would  be  required  is  un- 
known. Our  investigations  of  families  in  Chicago  show  that  the  total 
of  membership  certificates  and  policies  exceeds  the  number  of  wage- 
earners  insured  against  disabling  sickness  by  approximately  15  per  cent, 
some  insurance  men,  however,  have  ventured  the  opinion  that  the  number 
of  certificates  of  membership  in  funds  and  policies  would  have  to  be 
reduced  by  a  third  to  ascertain  the  number  of  persons  insured.  Of 
course  some  of  the  possible  errors  could  have  been  diminished  by  more 
extended  investigation.  More  extended  investigations  were  not  made 
to  arrive  at  the  most  accurate  general  estimate  because  a  difference  of 


147 

even  5  per  cent  is  of  little  importance  when  it  is  clear  tliat  ©nly  a  minority 
are  insured  against  sickness. 

It  would  appear  that  because  of  the  more  frequent  membership  in 
societies  that  provide  sickness  benefits  and  because  of  the  greater  responsi- 
bility resting  upon  them,  the  main  breadwinners  are  more  frequently 
insured  against  loss  of  time  caused  by  sickness  and  accident  than  are 
other  wage-earners.  With  this  important  exception,  there  is  reason  to 
believe  that  those  most  in  need  of  health  insurance  least  frequently 
have  it. 

There  are  a  number  of  reasons  why  sickness  insurance  is  less  ex- 
tensively found  than  life  insurance  and  death  benefits.  One  of  these 
is  that  the  organized  business  of  health  insurance  has  developed  more 
recently  than  the  organized  life  insurance  business.  It  has  not  been 
so  frequently  called  to  the  attention  of  prospects  and  advertised.  An- 
other is  that  the  risk  of  sickness  does  not  make  such  strong  appeal  as 
the  risk  of  death.  A  third  reason  is  found  in  the  administrative  diffi- 
culties which  have  been  experienced  in  providing  such  insurance.  The 
organizations  which  because  of  simulation  or  malingering,  have  dis- 
continued or  limited  their  writing  of  health  insurance  are  by  no  means 
few.  A  fourth  reason  is  found  in  the  fact  that  except  in  the  majority 
of  establishment  funds  and  a  few  other  instances,  the  entire  cost  has  been 
borne  by  the  insured,  and  when  the  cost  is  undivided,  the  necessary 
premiums  are  heavy.  For  example,  many  labor  organizations  have 
regarded  the  cost  as  prohibitive  i.  e.  their  memebrs  regard  necessary  dues 
as  too  heavy.  A  fifth  reason  is  found  in  the  fact  that  most  organizations 
providing  loss  of  time  indemnities  or  sickness  benefits  have  had  and  have 
restrictive  rules  designed  to  protect  their  funds  against  those  whose 
insurance  would  involve  greatest  risk.  And,  finally,  most  of  the  in- 
surance has  provided  rather  meager  benefits  and  these  usually  have  been 
limited  to  a  comparatively  short  period — most  frequently  to  13  weeks  in 
the  year,  with  the  result  that  it  has  been  less  attractive  than  it  would 
have  been  with  more  ample  benefits.  Most  wage-earners  have  never  had 
sickness  insurance ;  many  of  those  who  have  had  it  have  left  the  union, 
or  the  establishment,  or  the  society  providing  it,  or  have  failed  to  renew 
their  policies  by  paying  the  premiums  when  due. 

The  existing  insurance  varies  greatly  from  one  institution  to  an- 
other. The  outstanding  fact  is  that  while  better  standards  are  being 
developed,  it  has  not  become  standardized.  Most  frequently  it  provides 
only  cash  benefits  for  loss  of  time.'  In  some  instances,  though  they  are 
the  exception  and  not  the  rule,  the  waiting  period  is  in  excess  of  a  week 
and  may  be  regarded  as  unduly  long.  Much  more  important  are  tlie 
limitations  on  the  period  which  may  be  covered  by  claims  of  the  insured. 
Though  there  are  numerous  exceptions,  most  frequently  the  maximum 
period  is  13  weeks  in  the  year.  Where  the  maximum  is  only  13  weeks 
or  less,  the  provision  falls  short  of  good  standards  for  a  considerable 
number  of  cases  are  of  much  longer  duration  and  they  involve  the  greatest 
financial  strain.  Just  as  important  is  the  fact  that  while  there  are  ex- 
ceptions, the  benefits  paid  are  usually  inadequate  sums.  They  average 
less  than  $7  per  week  and  less  than  50  per  cent  of  wages.     Equally  im- 


148 


portant,  from  a  social  point  of  view,  are  the  restrictive  rules  which  pre- 
vent many  from  securing  insurance. 

Most  of  the  existing  insurance  against  sickness  is  provided  by  mutual 
organizations  democratically  governed.  Yet  there  are  some  exceptions 
to  this  where  compulsion  and  pressure  are  exercised  by  private  insti- 
tutions. 

Except  in  the  case  of  establishment  funds  (and  here  there  are  ex- 
ceptions) and  under  the  little  group  insurance  provided  by  employers, 
the  entire  cost  is  borne  by  the  insured.  The  public  makes  no  contribution 
and  the  contributions  made  by  industry  are  comparatively  small  when  all 
cases  are  considered  collectively.  For  the  most  part  the  cost  of  adminis- 
tration is  not  heavy;  most  of  the  money  contributed  in  dues  and  assess- 
ments by  the  insured  is  returned  in  benefits  to  the  disabled.  The  chief 
exception  found  is  where  individual  policies  are  issued  by  insurance 
companies.  The  casualty  companies,  largely  because  of  the  great  cost  of 
writing  policies  and  collecting  the  premiums,  have  paid  out  in  the  settle- 
ment of  claims  in  Illinois  less  than  42  cents  on  the  dollar  collected  in 
premiums.  A  number  of  the  companies  are  now  prepared  to  write  group 
policies  which  would  greatly  reduce  the  cost  of  acquisition,  but  little 
group  sickness  insurance  has  been  written  by  these  companies  and  it  is 
still  in  the  experimental  stage. 

The  existing  health  insurance  is  chiefly  for  the  partial  compensation 
of  wage  losses.  In  few  cases  are  maternity  benefits  provided.  Provision 
for  medical  care,  nursing  and  hospital  treatment  are  infrequently  made. 
Much  more  important  than  that  which  is  provided  by  the  various  in- 
surance institutions  is  the  provision  being  made  by  an  increasing  number 
of  the  leading  employers  through  the  development  of  their  welfare  and 
medical  departments. 

To  this  summary  statement  two  facts-  should  be  added.  While 
organized  labor  has  been  divided  on  the  question  of  compulsory  health 
insurance,  it  has  been  adversely  critical  of  such  insurance  of  working- 
men  as  is  not  provided  by  mutual  organizations.  The  new  Independent 
Labor  Party  has  inserted  in  its  platform  as  a  part  of  the  eighth  of  its 
"fourteen  points''  a  demand  for  "the  establishment  of  governmental 
insurance  against  accident  and  illness." 


149 


CHAPTER  V.     THE    COMMISSION'S    FINDINGS,    CONCLU- 
SIONS   AND    RECOMMENDATIONS. 


The  Commission  has  given  consideration  to  five  main  questions, 
viz:  (1)  What  is  the  problem  presented  by  sickness  and  death?  (2) 
^^^lat  is  being  done  in  Illinois  to  control  and  prevent  disease  and  to 
conserve  health?  (3)  What  is  being  done  to  care  for  the  sick  and  the 
physically  disabled?  (4)  What  is  being  done  to  compensate  for  loss  of 
earnings  and  to  meet  the  bills  caused  by  sickness  and  death?  And,  (5) 
What  more,  if  anything,  can  and  should  be  done  to  meet  the  situation 
as  found  by  investigation  ? 

The  Commission's  investigations  have  been  carried  on  under  the  able 
direction  of  its  Secretary  in  strict  adherence  to  the  policy  outlined  at  the 
organization  of  the  Commission,  namely,  that  the  investigations  shall 
be  as  thorough  as  the  limitations  of  time  and  money  will  permit  with  the 
single  purpose  of  ascertaining  the  facts  and  with  a  strict  regard  to 
scientific  accuracy  regardless  of  what  theory  may  be  supported  by  them, 
and  that  not  until  the  investigation  shall  be  completed,  the  facts  assembled 
and  the  completed  data  available,  shall  consideration  be  given  by  the 
Commission  to  the  formulation  of  any  conclusion  or  recommendation. 
Knowing  the  thoroughness,  the  singleness  of  purpose,  and  the  manner 
in  which  the  investigations  were  carried  on,  the  Commission  has  the 
utmost  confidence  in  basing  its  findings,  conclusions  and  recommendations 
upon  the  results  in  so  far  as  they  cover  the  m.any  phases  of  the  problems 
under  consideration  by  the  Commission. 

To  the  local  investigations  made  by  the  agents  of  the  Commission 
under  the  Secretary's  supervision  have  been  added  concise  reports  on 
compulsory  health  insurance  in  Great  Britain  and  Germany  and  on  the 
compulsory  health  insurance  movement  in  the  United  States.  These 
have  been  prepared  by  scholars  selected  as  well  qualified  for  the  tasks. 
The  results  of  the  several  investigations  have  been  set  out  in  necessary 
detail  in  the  four  chapters  presented  above  by  the  Secretary  and  in  the 
special  reports  which  follow.  In  this  Chapter  the  Commission  presents 
its  conclusions  and  its  recommendations  as  to  legislation  needed  to  meet 
the  situation  as  found  by  the  investigation. 

The  statute  creating  the.  Commission  limited  its  investigations  to 
wage-earners  and  their  families.  With  the  population  of  the  State,  July 
1,  1918  estimated  by  the  Federal  census  at  approximately  6,,300,000,  and 
the  proportion  of  these  gainfully  occupied  who  were  employed  as  wage- 
earners  in  1910  shown  to  be  in  excess  of  29  per  cent  of  the  whole,  the 
number  of  wage-earners  in  Illinois  on  July  1,  1918  is  estimated  at 
1,850,000,  and  their  dependents  at  something  over  2,700,000.  Accord- 
ingly the  group  embraced  within  the  investigations  required  of  the  Com- 


mission  may  he  estimated  a^^fiOO,000  or  more  than  seven-tenths  of  the 
entire  population.  It  is  apparent,  therefore,  speaking  broadly,  that  what- 
ever affects  the  wage-earners  and  their  families,  is  of  concern  to  the 
people  as  a  whole;  and  wiiatever  affects  the  people  as  a  whole  affects  the 
wage-earners  and  their  families.  It  is  evident,  moreover,  that  where  data 
are  not  available  for  that  portion  of  the  community  comprised  within  the 
group  of  wage-earners  and  their  families,  data  available  for  the  entire 
community  should  have  a  considerable  probative  value. 

1.  The  Pi'ohlem  of  sickness  and  Non-industrial  Accident — Stated. 

The  problem  of  sickness  has  been  set  out  in  terms  of  the  number 
disabled  by  sickness, .  the  number  ill  and  perhaps  in  need  of  medical 
treatment  though  not  disabled,  the  duration  and  cost  of  sickness,  changes 
in  standards  of  living,  poverty,  and  dependency. 

(a)   The  Number  III  at  a  Given  Time. 

Seven  investigations  made  by  the  Metropolitan  Life  Insurance  Com- 
pany in  as  man}'  communities  show  that  1.83  per  cent  of  the  633,856 
persons  canvassed  were  unable  to  work  because  of  sickness  or  non-in- 
dustrial accident  on  the  days  the  enquiries  were  made.  This  percentage 
shows  the  number  who  may  be  expected  to  be  disabled  at  a  given  time  by 
reason  of  sickness  or  accident  for  following  their  ordinary  pursuits. 
This,  however,  does  not  show  the  number  who  have  disabilities  which 
may  impair  efficiency  and  which  may  call  for  treatment.  Medical  ex- 
aminations made  of  4,573  persons  at  Framingham,  Massachusetts,  showed 
that  25  per  cent  had  what  were  classed  by  the  examining  physicians  as 
"serious  affections."  Approximately  35  per  cent  of  the  2,510,706  young 
men  examined  in  the  first  draft  were  rejected  as  not  meeting  army 
standards.  Returns  of  the  results  of  the  physical  examinations  of  69,171 
applicants  for  work  in  Illinois  shoAV  that  about  the  same  percentage 
(33.1)  were  found  to  be  diseased  or  defective  and  that  19  per  cent  of 
the  69,171  were  rejected  as  not  physically  suitable  for  the  work  applied 
for.  In  all  of  the  above  cases  it  is  disclosed  that  many  of  the  affections, 
diseases  or  defects  had  existed  since  childhood.  It  therefore  need 
occasion  no  surprise  to  find  that  37,356  or  47.1  per  cent  of  79,383 
Chicago  school  children  examined  in  1915  were  found  to  be  diseased  or 
physically  defective  and  that  32,860  of  them  were  advised  to  secure 
treatment.  Investigation  has  shown  that  the  number  of  diseased  and 
defective  children  is  likely  to  be  larger  in  rural  communities  than  in 
such  urban  communities  as  Chicago. 

In  connection  with  these  facts  it  should  be  'said  that  the  percentage 
of  rejections  because  of  failure  to  meet  a  physical  standard  required  for 
army  service  or  some  fonns  of  industrial  work  is  not  the  percentage 
physically  unfit  for  work  of  some  other  kind.  The  character  of  the 
service  in  connection  with  which  a  standard  is  established  is  always  an 
important  consideration.  For  example,  many  of  those  rejected  in  the 
first  draft  for  failure  to  meet  the  standard  required  for  active  military 
service  were  nevertheless  suitable  for  limited  service  and  were  later  so 
classified  and  did  carrv  on  duties  connected  with  the  armv  org^anization 
which  did  not  require  the  exacting  physical  demands  of  the  active  mili- 


151 

tary  service.  Xevertheless,  it  is  safe  to  say  that  in  addition  to  those 
disabled  by  sickness  at  any  given  time,  between  20  and  30  per  cent  of  all 
persons  not  so  disabled  may  be  expected  to  have  disease  or  physical  defects 
for  which  treatment  would  be  beneficial. 

(b)   Sickness  Experience  of  a  Year. 

Number  sick. — In  an  effort  to  secure  the  most  detailed  information 
required  for  its  purposes  the  Commission  has  had  an  investigation  made 
of  all  families  living  in  41  blocks  in  Chicago,  these  being  occupied 
chiefly  by  wage-earning  families  and  carefully  selected  so  as  to  be  typical 
of  the  much  larger  number  of  wage-earning  families  in  the  City.  These 
"Block  Studies"  covered  3,048  families  with  12,450  members.  It  was 
found  that  65.8  per  cent  of  these  families  had  one  or  more  cases  of 
serious  illness  during  the  twelve  months  ending  with  the  date  of  the 
visit  made  by  the  investigators.  "Serious  illness"  was  defined  so  as  to 
include  all  cases  of  disability  for  work  or  school  for  a  week  or  more 
caused  by  sickness  or  non-industrial  accident,  all  cases  of  serious  chronic 
affections,  such  as  tuberculosis,  regardless  of  whether  or  not  they  caused 
such  disability  at  any  time  for  as  much  as  a  week,  and  serious  affections, 
such  as  of  the  tonsils,  of  shorter  duration  provided  a  doctor  or  surgeon 
was  secured  to  give  needed  treatment.  Of  the  2,708  wage-earning  fami- 
lies in  these  blocks,  66.5  per  cent  had  one  or  more  cases  of  serious  illness 
as  thus  defined.  In  57.4  per  cent,  or  more  than  half  of  the  1,802  wage- 
earning  families  with  sickness  one  or  more  wage-earners  had  been 
seriously  ill.  Of  the  entire  number  of  wage-earners  27.3  per  cent  had 
been  ill  and  (counting  only  losses  of  a  duration  of  a  week  or  more) 
20.9  per  cent  of  them  had  lost  a  week  or  more  of  work  because  of  their 
disabilities.  The  relative  number  of  non-wage-earners  in  these  families 
reported  as  having  been  seriously  ill  was  somewhat  larger — 28.3  per  cent. 

An  examination  has  been  made  of  the  records  of  a  large  number  of 
mutual  benefit  associations  of  different  types.  Nine  of  these,  covering 
the  experience  of  663,163  wage-earners,  showed  that  19.9  per  cent  of 
them  were  compensated  in  the  course  of  a  year  for  disabilities  lasting 
for  a  week  or  more  at  a  time,  with  an  average  period  of  disability  of  27.4 
days  per  case.  Combining  results  obtained,  it  is  probable  that  20  per 
cent  of  all  wage-earners  Avill  be  disabled  for  more  than  7  days  in  the! 
course  of  a  year  by  a  sickness  or  non-industrial  accident,  with  an  average 
of  between  27  and  29  days  for  each  wage-earner  disabled.  All  disabling 
sickness  of  one  day  or  more  spread  over  the  entire  group  would  indicate 
an  average  loss  of  working  time  of  between  8  and  9  days  for  each  wage- 
earner. 

Duration  of  disability. — ^This  average  is,  however,  of  limited  value 
in  stating  the  problem  of  sickness  among  wage-earners  for  the  duration 
of  the  disability  varies  greatly  from  one  case  to  another.  The  data 
collected  and  set  out  in  detail  elsewhere  (in  Special  Eeport  II,  Part  II) 
indicate  that  of  each  100  disabled  for  more  than  a  week,  65  will  be  dis- 
abled for  less  than  4  weeks,  19  for  from  4  to  8  weeks,  7  for  from  8  to  12 
weeks,  6  for  from  12  to  27  weeks,  3  for  more  than  6  months,  and  1.29 
for  more  than  a  year.     Put  in  terms  of  lost  wages,  the  investigations 


152 

made  in  Chicago  show  that  56.1  per  cent  of  those  losing  wagesynosl 
less  than  10  per  cent  and  76.2  per  cent  less  than  20  per  cent  of  what  their 
annual  earnings  would  have  been  had  they  not  been  reduced  by  dis- 
abling sickness.  Expressed  in  the  other  way,  it  was  found  that  of  those 
who  lost  wages  (which  constituted  one-fifth  of  the  entire  group)  43.9 
per  cent  lost  10  per  cent  or  more  and  23.8  per  cent  lost  20  i^r  cent  or 
more  of  what  their  earnings  would  have  been.  Expressed  in  terms  of 
the  wage-earning  group,  it  is  indicated  that  20  per  cent  will  be  disabled 
for  more  than  one  week,  13  per  cent  for  more  than  one  week  and  less  than 
four  weeks,  7  per  cent  for  four  weeks  or  more,  3.2  per  cent  for  eight 
weeks  or  more,  1.8  per  cent  for  twelve  weeks  or  more,  .6  per  cent  for  more 
than  six  months;  that  of  the  entire  group  of  wage-earners  it  may  be  ex- 
pected that  8.8  per  cent  will  lose  10  per  cent  or  more  and  4.8  per  cent 
will  lose  20  per  cent  or  more  of  what  their  earnings  would  have  been 
but  for  disabling  sickness. 

Cost  of  sickness. — In  the  investigation  of  wage-earning  families  in 
the  residence  blocks  selected  in  Chicago,  an  effort  was  made  to  ascertain 
the  money  cost  of  sickness.  The  average  wage  loss  of  wage-earners  dis- 
abled for  a  week  or  more  at  a  time  was  found  to  have  been  $119  and  13.7 
per  cent  of  what  their  earnings  would  have  been  but  for  the  disability. 
Spread  over  the  4,474  wage-earners  in  these  families  this  represents  an 
average  loss  of  $24.95  per  man  and  3.33  per  cent  of  his  earnings  for 
these  averaged  $750.37  for  the  year.  To  each  dollar  of  lost  wages  it 
was  found  that  approximately  25  cents  must  be  added  for  medical  bills 
paid.  Of  course  the  wage-earners  bear  the  medical  bills  of  their  de- 
pendents also.  This  same  investigation  showed  that  for  each  wage- 
earning  family  in  which  there  had  been  illness  of  the  types  recorded,  the 
average  cost  for  the  year  in  wages  lost  at  the  time  of  disabling  sickness 
and  in  medical  bills  paid  was  $97.98.  Taking  these  losses  and  outlays 
and  the  medical  bills  paid  where  there  was  no  serious  illness,  the  cost 
in  wages  lost  and  medical  outlays  was  found  to  approach  $75  per  family 
per  year.  This  is  more  than  5.8  per  cent  of  their  incomes  from  all 
sources,  for  these  were  found  to  average  $1,298  per  family.  If  these 
figures  can  be  applied  to  the  entire  State,  it  would  mean  that  the  cost  of 
disabling  sickness  of  wage-earners  alone  in  Illinois  would  be  about 
$57,000,000.  If  to  this  is  added  the  medical  bills  paid  for  their  de- 
pendents the  cost  of  sickness  in  the  wage-earning  families  of  the  State 
would  be  between  $80,000,000  and  $86,000,000  per  year. 

Changes  in  standards  of  living  due  to  sickness. — Any  estimate 
arrived  at  in  the  manner  here  emploved,  does  not,  of  course,  show  the 
entire  cost  of  sickness  among  wage-earners  and  their  families.  There 
may  be  losses  because  of  reduced  wages  due  to  impaired  efficiency;  cer- 
tainly not  all  of  the  cost  of  treatment  is  paid  for.  In  the  family  in- 
vestigations to  which  several  references  have  already  been  made,  it  was 
found  that  in  14.3  per  cent  of  the  families  with  sickness  (or  16  per 
cent  of  those  with  medical  attention)  the  physician's  services,  in  7 
per  cent  (or  57  per  cent  of  those  with  nursing  care)  the  nurses'  services, 
in  10.5  per  cent  (or  50  per  cent  of  those  who  received  hospital  care)  the 
hospital  facilities,  in  19.3  per  cent  (or  60  per  cent  of  those  visiting  dis- 


153 

pensaries)  the  dispensary  treatment,  in  4  per  cent  the  medicines  supplied 
had  been  without  charge;  These  percentages,  it  should  be  added,  do 
not  include  the  free  services  of  physicians  at  dispensaries  or  the  nursing 
incidental  to  free  hospital  service,  or  the  medicine  in  some  ca^es  supplied 
by  the  dispensary  or  the  physician  where  no  charge  was  made  for  treat- 
ment. It  should  be  said,  moreover,  that  where  fees  were  paid  for  dis- 
pensary service  these  usually  covered  only  a  fraction  of  the  cost.  It  is 
evident  that  no  small  part  of  the  cost  of  sickness  among  wage-earners 
and  their  families  is  borne  not  by  them  but  by  the  doctors,  the  nurses, 
the  dispensaries,  or  by  others. 

Our  investigation  of  families  shows  that  in  a  considerable  percentage 
of  cases  the  wife  or  others  who  had  not  been  gainfully  occupied  sought 
emploj^ment  to  meet  the  emergency  presented  by  sickness  of  those  losing 
working  time.  It  shows,  also,  that  in  spite  of  this,  of  added  economy, 
and  of  other  things  involving  a  change  in  standards  of  living,  16.6  per 
cent  of  the  wage-earning  families  with  sickness  had  deficits  for  the  year. 
That  these  deficits  were  largely  due  to  sickness  is  indicated  by  the  fact 
•that  only  4.7  per  cent  of  the  families  without  sickness  had  deficits.  In 
covering  deficits  sustained  some  had  used  savings,  others  had  secured 
material  relief  from  charitable  agencies,  had  secured  loans,  or  had  used 
insurance  received,  while  still  others  left  bills  unpaid.  Material  relief 
in  the  form  of  charity  was  received  by  2.4  per  cent  of  the  families  in 
which  there  had  been  sickness,  or  1.8  per  cent  of  the  entire  number  of 
the  families  investigated. 

(c)   Poverty  and  Dependency  Eesidting  from  Sickness. 

The  Commission  was  especially  interested  in  ascertaining  the  ex- 
tent to  which  sickness  and  non-industrial  accidents  are  responsible  for 
poverty  and  dependency.  If  poverty  is  defined  in  terms  of  a  family 
income  too  small  to  meet  the  test  of  a  conservative  subsistence  budget, 
our  investigations  of  families  in  the  41  Chicago  blocks  show  that  sickness 
was  responsible  for  about  one-fourth  (25.3  per  cent)  of  the  375  cases 
found  in  the  grand  total  of  2,589  wage-earning  families  for  which  com- 
plete data  in  respect  to  incomes  were  obtained. 

In  the  investigation  of  the  relation  between  sickness  and  non-in- 
dustrial accident  and  dependency,  a  study  was  made  of  the  records  of  a 
number  of  charity  organizations  in  the  smaller  cities  of  the  State,  and 
of  three  charitable  agencies  in  Chicago — the  former  for  the  last  fiscal 
year,  the  latter  for  a  period  of  eight  3^ears.  Sickness  was  found  to  have 
been  a  cause  or  an  accompanying  condition  of  dependency  in  from  a  third 
to  half  of  the  cases.  Moreover,  this  study  and  the  investigation  of  628 
families  in  receipt  of  material  relief  from  Chicago  agencies  indicated 
that  from  40  to  50  per  cent  of  the  cases  where  sickness  was  a  cause  or 
condition  of  dependency,  the  disability  was  due  to  tuberculosis  or  other 
chronic  diseases — tuberculosis  and  other  chronic  diseases  sharing  about 
an  equal  degree  of  responsibility.  The  special  problem  of  tuberculosis 
is  discussed  below. 

(d)  A  summary. — The  above  is  presented  as  a  summary  statement 
of  the  more  important  facts  bearing  upon  the  problem  of  sickness  as  dis- 


154 


closed  by  our  investigations.  In  a  sentence  we  find:  (1)  that  somewhat 
less  than  2  per  cent  are  disabled  by  sickness  or  accident  at  a  given  time ; 
(2)  that  the  percentage  not  disabled  but  who  have  serious  affections  which 
may  call  for  medical  care  is  distinctly  larger;  (3)  that  approximatelv 
two-thirds  of  the  wage-earning  families  will  have  one  or  more  cases  of' 
serious  sickness  or  non-industrial  accident  in  the  course  of  the  year;  (4) 
that  in  something  more  than  half  of  these  families  the  illness  will  in- 
clude that  of  wage-earner;  (5)  that  something  more  than  a  quarter  of 
the  wage-earners  will  be  sick  or  sustain  non-industrial  accident  in  the 
course  of  the  year  and  that  about  a  fifth  of  the  entire  number  will  lose 
a  week  or  more  of  employment  because  of  the  disability  caused  thereby; 
(6)  that  the  loss  of  time  by  wage-earners  will  average  between  8  and  9 
days  per  year  for  each  wage-earner  in  the  entire  group;  (7)  that  the 
losses  due  to  sickness  and  non-industrial  accident  are  very  unevenly  dis- 
tributed among  wage-earning  families;  (8)  that  the  average  loss  in  wages 
and  medical  bills  connected  with  sickness  and  accident  will  approach  $75 
per  year  per  family  when  spread  over  the  entire  group,  amounting  to  5% 
per  cent  or  more  of  the  average  family  income;  (9)  that  the  money  cost» 
of  sickness  and  non-industrial  accident  borne  by  the  wage-earners  of 
Illinois  is  probably  between  $80,000,000  and  $86,000,000  per  year;  (10) 
that  sickness  and  non-industrial  accident  are  frequently  accompanied  by 
more  or  less  important  changes  in  the  standard  of  living;  (11)  that  they 
give  rise  to  deficits  in  a  substantial  number  of  cases;  (13)  that  in  Chicago 
sickness  and  non-industrial  accident  would  appear  to  be  responsible  for 
25.3  per  cent  of  the  cases  of  poverty  found  in  our  investigations;  (13) 
that  sickness  and  non-industrial  accident  are  found  as  a  cause  or  as  an 
accompanying  condition  of  dependenc}^  in  from  a  third  to  a  half  of  the 
cases  of  dependency  not  giving  rise  to  institutional  care;  and  (14)  that 
tuberculosis  and  other  chronic  diseases  are  each  found  in  from  20  to  25 
per  cent  of  the  cases  where  sickness  is  a  cause  or  condition  of  dependency. 

2.  Illinois  Vital  Statistics. 

An  examination  has  been  made  of  the  vital  statistics  of  Illinois  to 
secure  such  light  as  they  might  shed  upon  the  problems  which  the  Com- 
mission has  had  under  investigation.  Unfortunately  the  only  reliable 
vital  statistics  for  the  State  as  a  whole  are  those  for  the  year  1917-18. 
These  show  that  the  general  death  rate  (14.2  per  1,000)  for  the  State 
as  a  whole  corresponds  closely  to  that  for  the  entire  registration  area 
of  the  United  States  (14.0)  as  shown  by  the  Census  Mortality  Statistics 
for  1916.  This  would  indicate  that  there  is  nothing  peculiar  in  the 
general  problem  of  disease  and  fatal  illness  in  Illinois. 

While  acceptable  data  for  the  State  covering  a  period  of  years  are 
not  available,  there  can  be  no  doubt  that  in  Illinois  there  has  been  a 
declining  death  rate,  closely  corresponding  to  that  shown  by  the  Census 
for  the  registration  area.  The  reduction  there  shown  is  from  19.8  per 
thousand  in  1880  to  14.0  per  thousand  in  1916.  In  Chicago  where, 
fortunately,  acceptable  figures  are  available,  the  death  rate  decreased 
from  20.27  in  1887  to  14.92  in  1917.  The  seven  other  cities  of  the 
State  which  have  been  registration  cities  for  a  number  of  vears  show  in 


155 

general  a  similar  decrease.  The  decrease  in  the  rural  communities  of 
Illinois  is  not  known,  but  the  registration  area  as  a  whole  shows  that  the 
decrease  in  the  cities  is  greater  than  in  the  rural  districts. 

In  Chicago  the  period  from  1887  to  1917  has  witnessed  a  decrease  in 
the  death  rates  from  typhoid,  pulmonary  tuberculosis,  croup,  diphtheria, 
scarlet  fever,  measles  and  whooping  cough,  but  an  increase  in  the  death 
rates  from  pneumonia,  cancer,  Bright's  disease,  and  heart  disease.  The 
improvement  in  the  water,  milk  and  food  supplies  and  in  sanitary  con- 
ditions, a  better  understanding  of  matters  affecting  health,  the  control 
of  communicable  diseases,  the  advance  in  medical  and  surgical  service  and 
practice,-  and  the  improvement  in  the  hospital  and  other  facilities  for 
treatment  and  cure  have  all  contributed  to  the  reduction  in  the  death 
rate.  This  is  most  marked  in  the  reduction  of  deaths  of  children  and 
has  been  not  nearly  so  great  in  middle  life.  The  death  rate  among 
persons  past  fifty  years  had  increased.  It  is  a  question  whether  the 
increase  in  the  death  rate  from  degenerative  diseases  and  of  the  age 
group  past  fifty  years  is  to  be  explained  by  more  accurate  diagnosis  and 
by  the  bringing  to  adult  life  of  children  of  less  than  normal  vitality  who 
would  have  died  in  childhood  but  for  the  advance  in  disease  control  and 
treatment,  thus  increasing  in  the  adult  age  groups  the  proportion  of 
those  with  less  than  normal  vitality,  or  whether  the  increase  is  indicative 
of  a  condition  of  modern  life  which  can  be  corrected. 

While  the  general  vital  statistics  available  for  Illinois  show  a  favor- 
able result  when  compared  with  those  for  other  cities  and  states,  the 
data  available  for  Chicago  relating  to  deaths  of  children  under  2  years  of 
age  from  enteritis  and  diarrhea  do  not  make  a  favorable  showing.  Tak- 
ing the  death  rates  per  100,000  of  total  population  in  cities  of  500,000 
and  over,  the  death  rates  from  enteritis  for  Chicago  have  shown  a 
tendency  to  increase  since  1901  while  in  New  York,  St.  Louis,  Boston  and 
some  other  cities  they  have  been  reduced  materially.  Xew  York,  for 
example,  had  an  annual  average  for  1901  to  1905  of  145  deaths  per 
100,000,  which  was  reduced  to  58.1  in  1916.  Chicago,  on  the  other  hand, 
had  an  incerase  from  104.4  for  1901  to  1905  to  131  in  1914;  112.7  in 
1915,  and  141.4  in  1916.  It  would  appear  that  considerable  room  for 
improvement  is  indicated  by  these  figures  for  in  1916  the  Chicago  Health 
Department  found  that  3,450  or  40.9  per  cent  of  the  8,421  deaths  of 
children  under  2  years  of  age  were  due  to  diarrhea  and  enteritis. 

3.  The  Causes  of  and  Responsibility  for  Disease. 

The  cause  of  and  responsibility  for  disease  is  here  presented,  not 
from  a'medical  viewpoint,  but  from  a  consideration  of  the  claim  that  the 
community  or  State,  industry  and  the  individual  are  in  varying  pro- 
portions responsible  for  sickness  and  premature  death. 

A  case  of  typhoid  may  be  traced  to  the  failure  of  the  municipality 
properly  to  control  the  purity  of  the  water  or  milk  supply ;  but  what  of 
the  typhoid  cases  otherwise  caused?  The  failure  of  the  public  autliori- 
ties  properly  to  control  a  contagious  disease  may  contribute  to  its  spread ; 
but  what  of  the  contagious  cases  caused  by  the  insistence  of  the  in- 
dividual upon  his  right  of  personal  liberty  and  self-determination  in 


156 

matters  relating  to  disease  and  accepted  medical  treatment  and  control 
thereof  ? 

A  well-defined  occupational  disease  may  properly  be  considered  as 
caused  by  the  industry  in  which  are  employed  those  who  suffer  from  the 
disease ;  but  what  of  the  diseases  which  are  commonly  found  in  all  with- 
out regard  to  occupation  and  which  are  not  limited  to  those  in  a  given 
occupation?  Even  though  in  a  given  employment,  the  incidence  of  dis- 
ease may  be  found  in  excess  of  the  average  for  that  disease  among  the 
people  generally,  and  may  indicate  that  there  are  conditions  within  the 
employment  which  are  contributing  to  the  disease,  it  is  obvious  that  the 
responsibility  of  the  particular  establishment  is  not  an  index  as  to  the 
responsibility  of  industry  collectively. 

Assuming  a  working  day  of  proper  length  for  the  normal  worker, 
can  it  be  properly  said  that  exhaustion  or  resulting  disability  of  the 
one  unable  to  meet  such  standard  is  caused  by  the  industry,  and  should 
it  be  held  responsible  unless  each  worker  is  examined  to  determine,  if 
possible,  whether  he  is  physically  suited  for  the  job?  In  order  to  de- 
termine whether  the  worker  is  physically  able  to  do  the  work  which  he 
would  undertake,  should  industry  be  compelled  in  the  interest  of  the 
worker  to  examine  him  physically  before  assignment  to  such  work  ?  Un- 
less such  examination  is  made  with  the  right  of  control,  is  the  industry 
to  be  held  responsible  for  the  result  ? 

In  our  opinion  nearly  all  disease  is  traceable  in  its  ultimate  caus- 
ation to  the  individual,  to  the  violation,  through  lack  of  understanding 
or  willfulness,  of  the  well-recognized  laws  of  health  or  hygiene;  the  re- 
fusal to  use  the  facilities  for  correction  of  physical  conditions  which 
will  become  disabling;  excesses  in  personal  conduct;  and  a  most  im- 
portant factor,  the  inherent  limitations  of  vitality  which  vary  in  indi- 
viduals from  those  merely  able  to  keep  alive  the  spark  of  life  to  those  who 
are  of  the  most  robust  ajid  vigorous  type. 

The  foregoing  is  not  intended  as  a  complete  statement  of  the  causes 
of  disease  and  responsibility  therefor,  but  merely  to  illustrate  what  is 
indubitably  the  fact  that  causation  or  responsibilty  for  disease  cannot  be 
rationally  assigned  on  the  basis  of  a  classification  of  diseases,  with  the 
possible  exception  of  diseases  to  which  workers  in  an  occupation  are  ex- 
posed and  which  are  not  found  among  those  who  are  not  engaged  in  that 
occupation. 

Any  statement  of  a  proportional  responsibility  of  the  State,  in- 
dustry or  the  individual  as  factors  causing  disease  in  the  aggi'egate  is 
without  basis  in  ascertained  fact  or  creditable  evidence. 

4.  Health  Legislation  and  Public  Health  Administration. 

'    The  Commission  has  also  given  consideration  to  the  effort  which  has 
been  made  to  control  disease  and  to  conserve  health. 

The  State  now  has  in  effect  much  legislation  designed  to  protect 
Health — the  Gannent  Law;  the  Blower  Law;  the  Health,  Safety  and 
Comfort  Law;  the  Occupational  Disease  Act,  and  a  number  of  other 
statutes.  However,  two  noteworthy  gaps  in  the  legislation  now  in  effect 
are  to  be  found  in  the  absence  of  any  State  legislation  relating  to  the  medi- 


157 

cal  examination,  nursing  and  clinical  treatment  of  school  children  and  in 
the  absence  of  a  building  code.  Mandatory  or  permissive  laws  relating  to 
the  health  supervision  of  school  children  are  now  found  in  no  fewer  than 
25  of  the  States.  It  seems  to  be  accepted  opinion  that  not  only  should 
there  be  medical  inspection  of  school  children  for  the  detection  of  cases  of 
contagious  diseases,  but  also  annual  physical  examinations  to  detect  other 
diseases  and  physical  defects  which  should  receive  treatment,  and  to  in- 
dicate needed  adaptation  to  school  work;  also  sight  and  hearing  tests, 
nursing  service,  not  only  in  the  schools,  but  for  follow-up  work,  and  pro- 
vision in  school  clinics  and  the  like  for  such  medical,  dental  and  ophthal- 
mic treatment  as  is  needed  to  supplement  that  which  the  families  provide 
privately  for  their  children.  The  Commission  is  not  prepared,  however, 
to  recommend  for  adoption  in  this  State  any  definite  legislation  relating 
to  this  matter. 

First  to  be  mentioned  in  public  health  administration  is  the  De- 
partment of  Public  Health,  which,  as  reorganized,  was  established  by  the 
Civil  Code  adopted  in  1917.  Though  handicapped  by  a  comparatively 
small  appropriation,  it  is  undertaking  an  important  work  in  coordinating 
and  standardizing  the  public  health  work  of  the  State.  For  the  great;er 
part,  its  powers  and  duties  are  investigative  and  advisory.  The  chief 
exception  is  found  in  the  powders  which  are  given  it  to  suppress  dangerous 
contagious  and  infectious  diseases  that  have  become  epidemic  and  when 
local  authorities  have  failed  to  act  promptly  and  efficiently.  Modern 
conditions  call  for  a  strong  and  liberally  supported  State  Department 
of  Pubic  Health  if  disease  is  to  be  successfully  combated  and  health 
conserved.  Although  in  some  of  the  municipalities,  the  local  health 
administration  is  strong  and  efficient,  this  is  not  true  in  most  of  the 
localities  and  the  State  Department  should  be  vested  with  power  to  direct 
and  control  in  those  matters  which  affect  the  health  of  the  people 
generally. 

In  many  parts  of  the  State  the  local  health  work  has  not  been 
efficiently  undertaken.  An  analysis  made  by  the  State  Department  of 
Public  Health  of  reports  from  343  health  districts  shows  the  limited 
public  health  nursing  service ;  the  limited  amount  of  public  child  hygiene 
work;  a  limited  number  of  public  child  welfare  stations;  a  large  number 
of  places  in  which  no  campaign  has  been  made  to  secure  a  complete  re- 
porting of  births  and  deaths ;  a  number  of  cities  without  proper  sewerage 
systems;  the  exceptional  cases  in  which  public  provision  is  made  for  dis- 
posal of  garbage ;  the  neglect  of  the  water  supply  which  frequently  cannot 
be  reported  as  safe ;  the  infrequent  building  codes ;  the  frequent  absence 
of  regulations  relative  to  .privies ;  the  fairly  general  failure  to  inspect 
dairies  with  the  result  that  the  conditions  in  dairies  arc  frequently  un- 
satisfactory or  bad ;  the  frequent  failure  to  report  communicable  disease 
fully ;  the  general  absence  of  laboratories  for  health  work ;  and  the  short- 
comings in  handling  contagious  diseases. 

The  powers  of  the  State  Department  of  Public  Health  should  be 
enlarged  so  that  it  may  have  more  authority  to  direct  and  control  matters 
affecting  the  public  health. 


158 

TJie  Tuberculosis  Problem. 

Tuberculosis  ranks  first  among  the  causes  of  death  in  Illinois,  being 
assigned  as  cause  of  more  than  one  death  in  each  11  in  1917-18.  Pul- 
monary tuberculosis  has  its  greatest  incidence  among  adults  between 
the  ages  of  21  and  45,  and  is  of  frequent  occurrence,  therefore,  among 
workers  when  their  family  responsibilities  are  heaviest.  Of  the  men 
rejected  in  the  first  army  draft,  5.37  per  cent  were  rejected  because  of 
tuberculosis.  It  is  estimated  that  in  Chicago  there  are  60,000,  in  the 
State  outside  of  Chicago  50,000  active  cases  of  pulmonary  tuberculosis. 
Xot  only  is  tuberculosis  a  very  prevalent  disease;  it  is  also  one  of  rela- 
tively long  duration  and  frequently  reduces  families  to  poverty  and  de- 
pendency. As  already  stated,  our  investigations  show  that  from  20  to  25 
per  cent  of  dependency  is  caused  by  tuberculosis.  For  these  reasons  this 
disease  merits  special  consideration. 

Under  laws  now  in  effect,  public  sanatoria  and  dispensaries  have  been 
established  by  a  number  of  the  cities  and  counties  of  Illinois  for  the  free 
treatment  of  the  tuberculosis.  The  Department  of  Public  Health  has 
organized  a  division  of  tuberculosis  which  is  organizing  and  directing  a 
campaign  against  this  disease.  The  educational  activities  of  a  number 
of  organizations  are  also  an  important  factor  in  the  work  being  carried  on. 

The  problem  which  has  not  been  and  is  not  being  solved,  except  by 
charity,  is  the  fijiancial  one  of  supporting  the  dependents  of  the  tuber- 
culous wage-earner  whose  recovery  requires  that  he  should  stop  work 
while  under  treatment  at  the  sanitarium  or  at  home.  It  would  appear 
that  many  of  the  tuberculous  cannot  be  successfully  treated  if  they  con- 
tinue in  their  regular  employment.  Successful  treatment,  when  it  re- 
quires rest,  is  a  relatively  long  process.  If  the  tuberculous  man  re- 
mains at  home  he  is,  generally,  a  constant  menace  to  the  members  of  his 
family.  The  active  tuberculous  case  should  be  treated,  at  least  for  a 
time,  at  a  sanitarium,  thereby  removing  the  danger  to  others,  as  well  as 
providing  the  best  enviornment  for  his  care  and  treatment. 

It  appeared  in  evidence  before  the  Commission  by  tuberculosis 
specialists  with  wide  experience,  that  in  not  more  than  two  or  three  per 
cent  of  the  dispensary  patients  for  whom  rest  or  work  for  a  limited  num- 
ber of  hours  was  advised,  had  the  advice  been  followed,  for  the  reason  of 
the  economic  necessity  of  supporting  dependents.  A  large  number  of 
localities  have  provided  or  have  voted  to  provide  sanatoria,  the  facilities 
of  which  are  free  to  those  who  need  tuberculosis  treatment.  Provision 
should  now  be  made  for  the  payment  of  those  confined  in  such  sanatoria 
of  the  amount  of  the  earnings  which  they  would  be  able  to  make  but  for 
such  confinement,  in  order  that  the  facilities  provided  may  be  more  ex- 
tensively used. 

The  State  should  say  to  the  tuberculous  man:  "Your  life,  your 
health  and  that  of  your  family  and  dependents  is  too  important  to  be 
passed  without  an  effort  being  made  to  save  you  from  the  disease  which 
you  have  and  your  family  and  dependents  from  contracting  that  disease 
from  you.  In  the  view  of  society  as  it  exists  to-day,  you  are  presumed 
to  have  the  right  to  continue  to  do  as  you  please  in  your  own  home,  even 
tho\igh  it  may  result  in  inflicting  upon  your  wife  and  your  children  the 


159 

dread  disease  with  which  you  are  now  affected,  but  if  you  are  willing  to 
g'lYe  the  months — it  may  be  a  year  or  more — which  will  be  required  for 
your  treatment  in  a  public  sanitarium,  Society  in  consideration  of  your 
so  doing  will  pay  to  you  the  amount  of  the  earnings  which  you  otherwise 
would  make  during  such  periods  of  treatment.  You  give  your  time 
to  the  State  for  the  period  of  treatment  and  the  State  will  pay  you  for 
that  time.  You  may  completely  recover.  In  any  event,  your  family 
will  not  be  subjected  to  the  danger  of  contracting  the  disease  which  you 
have.     It  will  be  a  good  investment  for  you  and  for  the  State." 

In  the  opinion  of  the  Commission  the  County  Tuberculosis  Law 
which  provides  for  the  establishment  of  sanatoria,  should  be  so  amended 
as  to  make  provision  for  pa}Tnent  to  those  therein  confined  to  the  extent 
that  by  such  confinement  earnings  are  lost,  the  limit  of  payment  per  case 
to  be  $750  per  annum,  which  should  be  payable  in  semi-monthly  install- 
ments by  the  County  Commissioners  of  the  County  in  which  the  sani- 
tarium is  located  upon  certificate  that  the  one  to  whom  payment  is  made 
has  for  the  period  been  confined  in  the  sanitarium  for  treatment  and  has 
conformed  to  all  of  the  regulations  of  the  sanitarium.  The  certificate 
should  be  made  by  the  medical  officer  in  charge  of  the  sanitarium. 

6.  The  Prohlem  of  Venereal  Disease. 

Another  subject  meriting  special  consideration  is  that  of  venereal 
disease.  Congress  has  appropriated  $2,000,000  to  be  used  during  the 
two-year  period,  July  1918  to  July  1920,  in  venereal  disease  control. 
The  $1,000,000  set  apart  to  be  used  the  first  year  is  divided  among  the 
several  states  on  the  basis  of  population.  Illinois'  proportion  for  this 
first  year  is  something  over  $60,000.  This  money  is  to  be  used  for  edu- 
cation in  Social  Hygiene  and  in  the  prevention  and  treatment  of  venereal 
diseases.  In  Illinois,  this  program  is  being  carried  out  by  the  State 
Department  of  Public  Health  in  cooperation  with  the  United  States 
Public  Health  Service.  The  amount  of  money  available  in  Illinois  the 
second  year  under  the  Act  of  Congress  will  depend,  within  limits,  upon 
an  appropriation  of  a  like  amount  by  the  State.  Thus  an  appropriation 
of  $60,000  or  less  by  the  present  General  Assembly  for  venereal  disease 
control  in  Illinois  in  1919-20  will  be  augmented  by  a  like  sum  from  the 
national  government.  What  further  action  Congress  will  take  in  the 
matter  will  no  doubt  depend  largely  upon  the  success  of  this  experiment. 

Since  June,  1917,  the  reporting  of  venereal  diseases  in  Chicago  has 
been  required  by  ordinance.  More  recently  the  State  Department  of 
Public  Health  has  made  mandatory  the  reporting  of  these  diseases 
throughout  the  State. 

The  making  of  venereal  diseases  reportable  and  the  appropriation 
of  public  money  for  their  control  and  prevention  are  two  steps  of  pri- 
mary importance  in  the  campaign  against  these  diseases.  They  mark 
the  recognition  of  venereal  disease  as  a  community  problem  and  the  be- 
ginning of  community  action  for  their  control  and  possibly  their 
eventual  eradication. 

The  Commission  recommends  that  the  General  Assembly  now  co- 
operate fully  with  the  federal  government  by  appropriating  a  dollar  for 


160 


every  dollar  the  federal  government  has  shown  itself  willing  to  spend  in^ 
Illinois  in  venereal  disease  control.  ^ 

7.  Maternity  Care  and  Infant  Welfare  Work.  9 

For  the  most  part  the  Commission's  investigations  of  maternity  j 
care  have  been  incidental  to  the  family  investigation  in  Chicago.  This  \ 
investigation  showed  that  in  30.5  per  cent  of  the  695  confinement  cases 
covered,  all  or  a  part  of  the  care  was  furnished  free  to  the  family;  that 
in  41.5  per  cent  of  the  cases  a  mid-wife  was  the  attendant;  that  in  most 
cases  these  midwives  had  a  very  limited  training;  that  about  45  per  cent 
of  those  who  became  mothers  had  the  service  of  a  nurse  in  the  hospital, 
of  a  private  nurse  at  home,  or  a  visiting  nurse.  These  facts  obtained 
are  set  out  in  some  detail  elsewhere  in  this  report. 

It  is  stated  bv  the  Federal  Children's  Bureau  that  childbirth  and 
conditions  incident  thereto  cause  more  deaths  among  women  between  the 
ages  of  15  and  45  years  than  does  any  disease  except  tuberculosis,  and 
that  though  there  has  been  a  marked  decrease  in  the  death  rate  from  many 
preventible  diseases  during  the  last  decade  or  two,  there  has  been  no 
perceptible  decrease  in  the  death  rate  from  childbirth  and  attendant  con- 1 
ditions. 

The  total  deaths  from  childbirth  in  Chicago  during  1917  were  335, 
which  was  between  five  and  six  deaths  per  1,000  births.  The  death  rate 
of  infants  under  one  year  of  age  is  also  high.  Without  going  into 
further  detail  we  may  say  that  among  preventible  causes  of  death  of 
women,  childbirth  and  conditions  incident  thereto  rank  far  too  high  inj 
Illinois  as  does  the  attendant  infant  mortality  rate.  Two  Chicago  in-' 
stitutions  providing  skilled  pre-natal  and  obstetrical  care  to  patients, 
chiefly  in  their  own  homes,  show  exceptionally  low  maternity  and  infant 
mortality  rates.  In  both  cases,  the  number  of  deaths  in  confinement 
has  been  materially  less  than  one  per  thousand.  The  extension  of  such 
service  in  Chicago  and  throughout  the  State  would  greatly  reduce  the 
number  of  deaths  of  mothers  and  babies  at  the  time  of  childbirth  and 
from  conditions  closely  related  thereto. 

Accurate  data  relating  to  mortality  among  young  children  are  avail- 
able for  only  a  few  cities  in  the  State.  Such  data  as  are  available  and 
experience  indicate,  however,  that  there  are  great  possibilities  of  reducing 
the  death  rate  among  children  if  known  methods  of  care  were  more 
generally  applied.  Confidence  in  the  possibility  of  preserving  the  life 
of  babies  has  led  a  number  of  organizations,  both  public  and  private,  to 
direct  their  energies  into  this  work.  The  Elizabeth  McCormick  Memorial 
Fund  is  engaged  primarily  in  an  educational  campaign.  The  Infant 
Welfare  Society  of  Chicago  is  organized  very  largely  for  the  purpose  of 
caring  for  children  under  two  years  of  age.  It  maintains  infant  welfare 
stations  in  various  sections  of  Chicago  and  in  1917  employed  30  nurses. 
The  records  of  the  Society  show  that  the  mortality  of  babies  coming  under 
the  care  of  its  physicians  and  nurses  has  declined  from  4.2  per  cent  in 
1911'  to  2.2  per  cent  in  1918.  The  City  Health  Department  also  operates 
four  infant  welfare  stations.  Xursing  service  has  been  an  important 
factor  in  infant  welfare  work  and  the  reduction  of  mortality.     Work 


161 

similar  to  that  described  in  Chicago  is  being  carried  on  to  some  extent 
in  other  cities  and  towns  of  the  State.  Several  organizations  have  been 
found  that  devote  part  of  their  attention  to  this  problem.  There  are 
about  100  Public  Health  nurses  outside  of  Chicago  and  a  majority  of 
these  devote  a  part  of  their  time  to  infant  welfare  work. 

In  view  of  the  facts  enumerated  above  and  presented  in  much  more 
detail  in  Cha]|ter  II  the  Commission  recommends  the  appointment  of 
a  Commission  to  study  and  investigate  the  mortality  of  women  in  child- 
birth and  of  infants  in  the  State;  facilities  for  obstetrical  service;  and 
such  other  matters  relating  to  pre-natal,  obstetrical  and  post-natal  care 
as  affect  the  health  and  well-being  of  mothers  and  infants. 

8.  Hospital  Facilities. 

Measured  by  the  only  available  standard — the  ratio  of  hospital  beds 
to  population  in  the  United  States  as  a  whole — Illinois'  hospital  facilities 
are  inadequate,  being  only  62  per  cent  as  great  as  the  average  for  the 
country  as  a  whole.  The  ratio  for  Chicago  is  twice  that  for  the  rest  of  the 
State.  The  inadequacy  is  most  marked  in  the  smaller  towns  and  in 
rural  communities.  Yet  hospitals  are  so  supported,  constructed  and  I 
organized  that  their  actual  use  by  the  community  falls  far  short  of  their  I 
capacit3\  Taking  the  State  as  a  whole,  less  than  60  per  cent  of  the  maxi- 
mum facilities  of  the  privately  conducted  general  hospitals  were  used 
during  the  last  fiscal  3'ear,  notwithstanding  the  fact  that  the  maximum 
facilities  are  inadequate  in  relation  to  the  need.  Studies  made  by  the 
Commission  of  families  in  typical  wage-earning  communities  in  Chicago 
and  comprising  41  blocks,  show  that  399  or  20.9  per  cent  of  the  1,909 
families  reporting  sickness  costs  had  hospital  service  for  one  or  more 
members  during  the  3'ear.  Approximately  50  per  cent  of  these  families 
paid  for  the  service  and  50  per  cent  received  it  free.  This  and  other  facts  I 
indicate  the  need  not  only  for  more  hospital  beds  in  Illinois,  but  for  I 
increased  free  and  moderately  priced  hospital  service.  Hospital  facili- 
ties, both  as  to  quanity  and  as  to  the  amount  of  free  and  moderately 
priced  service,  are  much  more  nearly  adequate  in  Chicago  than  in  the 
rest  of  the  State. 

The  Commission  believes  that  a  partial  solution  of  the  hospital 
problem  in  communities  which  do  not  have  county  hospitals  lies  in  the 
establishment  of  public  county  hospitals.  Such  hospitals  should  be 
supported  by  the  county  out  of  public  funds,  should  provide  free  service 
for  those  unable  to  pa3',  but  should  also  be  available  for  patients  who  can 
pay.  The  county  tuberculosis  sanitarium  could  to  advantage  to  its 
patients  and  staff  be  made  a  unit  of  the  county  hospital.  Such  a  hospital 
should  have  an  obstetrical  department  the  facilities  of  which  should  be 
available  for  any  woman  in  the  county  needing  such  service.  In  the 
county  hospital  should  be  x-ray  and  laboratory  equipment  and  service 
avaiable  for  all  physicians  in  the  count3' — free  for  those  patients  need- 
ing it  free  and  furnished  for  pay  to  others.  Such  diagnostic  facilities 
may  well  be  provided  and  maintained  by  the  State  Department  of  Public 
Health.  Clinics  should  be  held  in  these  hospitals  for  the  treatment  of 
ambulatory  patients  needing  free  service  and  for  others  needing  treatment 

—11  H  I 


I 

J 


162 

which  can  be  adequately  given  only  in  such  an  institution.  Physicians 
who  attend  the  free  patients  in  such  a  county  hospital  should  be  com- 
pensated for  their  services.  Such  a  hospital  could  well  be  the  head- 
quarters of  the  county  health  officer  and  the  county  public  health  nurses- 
Such  an  institution  would  naturally  become  the  health  center  of  the 
county,  serving  the  people  of  the  county  in  the  solution  of  problems 
affecting  their  health. 

The  Commission  recommends  the  enactment  of  such  laws  as  may  be 
necessary  to  enable  counties  to  establish  such  hospitals,  and  the  State 
to  provide  and  maintain  diagnostic  facilities  therein. 

9.  Public  Health  Nursing. 

Public  health  nursing  is  making  a  distinct  contribution  to  health 
protection  and  conservation  in  Illinois.  Yet  outside  of  Chicago  and  two 
or  three  other  cities  this  type  of  public  health  work  is  not  well  developed. 
Infant  welfare  work,  protection  of  the  health  of  school  children,  home 
care  of  the  tuberculous,  prenatal  and  obstetrical  care  in  the  home  and 
other  important  phases  of  health  work  are  dependent  in  large  measure 
upon  efficient  and  ample  nursing  service. 

Because  of  the  importance  of  public  health  work  and  because  of  the 
value  of  nursing  service  as  a  part  of  it,  the  Commission  recommends  the 
provision  of  public  health  nursing  in  every  county  in  the  State. 

10.  Health  Insuran  ce . 

The  Commission  was  instructed  to  investigate  and  report  on  exist- 
ing health  insurance  and  on  proposals  made  for  adoption  in  this  or  other 
states.     Among  the  proposals  is  compulsory  health  insurance. 

Compulsory  health  insurance  is  the  phrase  commonly  used  to  desig- 
nate systems  which  exist  in  ten  European  countries  under  which  partial 
insurance  is  provided  against  the  losses  attendant  upon  sickness.  These 
countries  and  the  dates  the  systems  were  established  are  as  follows : 

Germany    1883      Serbia    1910 

Austria    1888     Great  Britain 1911 

Hungary    1891     Russia    1912 

Luxembourg   1901     Poumania    1912 

Norway    1909     The   Netherlands 1913 

The  essential  elements  of  the  systems  are: 

(1)  The  com]3alsorv  insurance  of  wage-earners  whose  income  is 
less  than  a  statea  amount. 

(2)  Insurance  may  be  carried  in  such  organizations  as  conform  to 
the  established  standards,  but  all  not  so  covered  are  insured  in  state 
or  district  organizations  created. 

(3)  The  cost  is  borne  by  the  employer,  the  employee  and  the  state 
in  varying  percentages.  In  England,  fof~example7me  percentages  are 
approximately  45,  35  and  20  per  cent  for  these  three  respectively. 

(4)  The  benefits  vary  but  generally  include : 

a.  A  cash  payment,  generally  from  50  to  60  per  cent  of  the 
wage  during  the  period  of  disability,  but  not  to  exceed  26  weeks. 


163 

b.  Medical  care  and  perhaps  surgical  and  hospital  services  and 
medicines  for  the  insured  or  for  the  insured  and  dependents. 

c.  Special  maternity  benefits  in  a  cash  sum  paid  at  the  time 
of  childbirth. 

d.  A  cash  payment  to  cover  the  cost  of  burial  of  the  insured. 
The  foregoing  is  a  brief  and  incomplete  summary.     It  is  presented 

here  to  indicate  generally  the  nature  of  the  established  systems.     In 
Chapter  IV  a  more  adequate  statement  will  be  found. 

The  establishment  of  compulsory  health  insurance  in  the  United 
States  has  been  advocated  for  several  years.  Commissions  to  investigate 
the  subject  have  been  appointed  in  eight  states.  The  Commissions 
of  California,  New  York  and  Ohjo  and  one  of  the  two  in  Massachusetts 
have  reported  in  favor  of  compulsory  health  insurance.  Those  of  Con- 
necticut and  Wisconsin  and  the  second  Commission  in  i!ttassachusetts 
have  reported  agailist  it. 

Bills  providing  for  compulsory  health  insurance  have  been  intro- 
duced in  several  states  in  this  and  previous  years.  No  state  has  as 
yet;,  passed  such  a  law.  Amendments  to  the  state  constitutions  of^ 
Massachusetts  and  California  were  proposed  so  as  to  Justify  the  enact- 
ment of  compulsory  health  insurance  laws.  The  Massachusetts  Consti- 
tutional Convention  did  not  adopt  the  amendment  proposed.  In  Novem- 
ber, 1918,  the  electorate  of  California  defeated  a  proposed  constitutional 
amendment  providing  for  compulsory  health  insurance  by  a  vote  of  about 
three  to  one. 

In  determining  whether  compulsory  health  insurance  should  be 
adopted  in  Illinois,  the  country  of  its  origin,  the  alleged  motives  of 
those  who  first  advocated  it  or  who  have  since  urged  or  opposed  it 
should  be  disregarded.     These  are  irrelevant  matters. 

Compulsory  health  insurance  should  be  tested  by  what  it  has  accom- 
plished; what  would  be  the  probable  result  in  Illinois;  whether  in  the 
light  of  the  need  for  and  the  effects  of  a  compulsory  health  insurance 
system  it  would  be  a  sound  public  policy  for  Illinois. 

In  arriving  at  a  conclusion,  the  best  interests  of  the  State  as  a 
whole  must  be  kept  constantly  in  mind  without  regard  to  any  special 
interest,  whether  it  be  that  of  the  wage-earners,  the  employer,  the  person ' 
insured  or  the  insurance  organization,  the  non-medical  practitioner  or 
the  licensed  physicians  and  surgeons;  that  of  those  who  would  and  of* 
those  who  would  not  be  insured;  of  those  now  dependent  upon  charity 
and  of  those  who  are  not;  of  those  who  would  receive  benefits  and  of 
those  who  would  not,  but  who  nevertheless  would  contribute  to  the  cost 
of  the  system.  Without  further  enumeration,  it  is^apparentjthat  a  com* 
pulsory  healtli  insuran?rfr-sfsteni  'comes  JncontacT  with  so  i!!HTry  in- 
teresfeofjfch^-dmmdAials  or  ^axtiips  who  constitute  Society  and_aiTegls 
them  sojtally-4hAt4^e^quS 

demand'''oriiecessity  and  the  welfare  of  the  people  of  the  State  as  a 
whole. 

Sickness  is  certaiiU-t£L..^g«ct^  substantial^m«jtm#v^-4^£-4h«-^age 
earners Tn~fTTeTourse  of  a  year,  because  eitheTthey  or  those  dependent 
upon  them  will  be  sick.     Considering  the  group  as  a  whole,. the  proba- 


164 

bility  for  a  year  is  susceptible  of  reasonable  determination.  Consider- 
ing the  individuals  of  the  group  upon  whom  the  incidence  of  sickness 
falls,  there  are  wide  variations  in  the  period  of  disability  and  in  the 
attendant  losses  caused  by  sickness.  The  uncertainty  as  to  whether  a 
given  individual  will  be  sick,  and,  if  sick,  as  to  the  loss  caused  thereby 
clearly  justifies  the  application  of  the  insurance  principle  to  the  sick- 
nesfl  hazard.  The  recognition  of  the  application  of  the  insurance  prin- 
ciple to  the  sickness  hazard  is  shown  by  the  compulsory  insurance  systems 
of  Europe  and  the  voluntary  insurance  now  provided  by  organizations  of 
different  types  in  Illinois. 

Insurance  against  the  sickness  hazard  is  now  provided  in  Illinois 
by  unions,  establislmifioit  funds  of  different  kinds,  fraternal  and  benevo- 
lent"^cieties,  independent  foreign  societies,  and  by  mutual  and  stock 
companies.  Some  of  the  last  named  are  writing  insurance  for  groups 
of  employees.  As  nearly  as  it  can  be  estimated  30  per  cent  of  the  wage- 
earners  of  the  State  now  have  health  insurance  provided  by  one  or  more 
of  these  organizations,  and  the  percentage  so  insured  has  been  increasing. 
In  the  "Block  Studies"  in  Chicago  it  was  found  that  while  only  23.7 
per  cent  of  all  the  wage-earners  were  insured,  36.7  per  cent  of  those 
who  were  the  main  support  of  families  had  insurance  against  sickness 
or  against  sickness  and  accident.  Of  the  wage-earners  who  were  the 
main  support  of  families,  approximately  three-fourths  had  life  insurance 
in  some  form,  averaging  $750  per  person.  This  ordinarily  becomes* 
available  for  the  pa3'ment  of  burial  expenses  as  well  as  for  meeting  the 
needs  of  d^endents. 

For  most  of  this  voluntary  insurance  the  employees  pay  the  entire 

XQst.  For  some,  however,  the  employers  and  the  employees  both  con- 
tribute, or  the  employer  pays  the  entire  cost.  The  cash  benefits  paid 
in  indemnification  of  wage  losses  vary  from  $2  to  $15  or  more  per  week, 
during  disability,  with  a  limitation  generally  of  from  13  to  26  weeks. 
This,  briefly,  is  the  existing  insurance  situation  as  found  in  Illinois. 
Wliat  has  compulsory  health  insurance  accomplished  in  those  countries 
where  it  has  been  adopted  ? 

There  is  no-  evidence  that  compulsory  insurance  has  resulted  in  an 
improvement  in  heal^  The  death  rates  and  morbidity  statistics  of  the 
countries  which  do  not  have  compulsory  health  insurance  show  a  decline 
fully  equal  to  that  of  the  countries  which  have  such  systems.  The 
explanation  is  probably  found  in  the  fact  that  compensation  for  wage 
losses  caused  by  sickness  hais  a  very  minor  effect  upon  health,  that  be- 
cause of  the  freedom  of  choice  of  physician  for  treatment'  (which  free- 
dom exists  even  under  the  compulsory  system)  the  quality  of  medical 
ser\2ceis_iiat-ii£^)roved,  that  the  advance  in  medical  science,  public  health 
CQfrtroL  educational  movements  for  better  personal  hygiene,  and  the 
many  factors  which  have  entered  into  the  prevention  of  disease,  have 
operated  with  equal,  if  not  greater  vigor  in  those  countries  which  do 

jiTot  have  compulsory  health  insurance.     It  seems  clear  that  compulsoryj 

I  health  insurance  is  not  an  important  factor  in  the  prevention  of  disease 

yor  in  the  conservation  of  health. 


165 

Compulsor}^  health  insurance  has  standardized  the  insurance  against 
losses  attendant  upon  the  sickness  of  wage-earaers.  It  provides  partial 
compensation  for  the  loss  of  wages,  and  provides  medical  care.  To  the- 
extent  individual  wage  losses  and  medical  costs  are  provided  for  a  ^.^ 
material  benefit  results.  Our  investigations  in  Chicago  show,  however, 
that  a  large  percentage  of  the  cases  of  poverty  caused  or  accompanied 
by  sickness  would  not  be  avoided  by  compulsory  health  insurance  of  the 
kind  that  has  been  proposed.  They  show,  also,  that  it  would  not  prevent 
as  much  as  a  fourth  of  the  cases  of  dependency  upon  charitable  agencies 
for  material  relief. 

The  systems  of  compulsory  health  insurance  established  and  the 
proposals  therefor  advocated  in  this  country  provide  for  payment  of  the 
cost  by  percentages  to  be  contributed  by  the  employer,  the  employee  and 
the  State.  Compensation  for  occupational  disease  should  be  provided 
by  the  employ (}!'  Ih  Whose  emplu3'menL  the  disease  is  Incurred.  'Occu- 
pational disease  lb  a  liazurd  p^jcidlcii'  Lu  iho  inductry  concerned.  It  is 
caused  by  that  industry.  With  non-occupational  diseases  the  case  i? 
different.  Tnrhistry  neithpr  (^puse^  snQh^  diseases  nor^does  it  benefit  from 
the  insurance  against  the  losses  caused^  by  {hem.  Tne  tae4s.«slK)uld  be 
fairly  met.  If  there  is  no  rational  basis  for  a  contribution  by  the  em-A 
ployer  the  requirement  that  he  shall  contribute  is  in  effect  an  increase  I 
in  the  wage  scale  established  by  law. 

Ten  cents  per  day  will  provide  the  wage-earner  with  all  the  insur- . 
ance  needed.     With  few  exceptions,  the  wage-earners  can  meet  the  cosi/ 
if  they  desire.     If  the  wage  paid  in  a  given  employment  is  not  sufficient, 
it  should  be  increased,  but  all  employers  should  not  be  charged  with 
an  increase  in  wages  because  of  the  failure  of  some  to  pay  a  living  wage. 

Likewise  the  burden  proposed  to  be  placed  upon  the  State  and  all 
employers  for  part  payment  of  the  cost  of  insurance  for  all  disease  of 
all  wage-earners  would  compel  the  State  and  employers  to  pay  for  that 
which  they  did  not  causQ  and  for  which  they  are  not  responsible  in  y^ 
any  real  or  tangible  sense.  The  proposal  for  proportional  contribution 
is  based  \n  its  ultimate  analysis  solely  upon  expediency. 

It  is  tht  expediency  of  obtaining  for  the  apyMcation  of  the  prin- 
ciple of  compulsion  the  support  of  the  immediate  beneficiaries  by  the 
appeal  that  the  cost  to  them  will  be  in  part  borne  by  the  State  and  the 
emploj'er;  the  expediency  of  compelling  a  financial  interest  in  the  system 
so  that  its  machinery  will  have  the  alleged  benefit  of  an  enlarged  judg- 
ment as  well  as  the  use  of  existing  Jjusiness  organization  for  the  col- 
lection of  premiums  through  the  employer. 

The  cost  of  compulsory  health  insurance  in  Illinois  would  be  be- 
tween $50,000,000  and  $60,000,000  annually,  conservatively  estimated 
on  the  basis  of  the  investigation  of  sickness  among  wage-earners  and  the 
attendant  costs.  The  annual  premiums  would  be  something  more  than 
the  annual  cost.  If  existing  health  insurance  carriers  were  used  and 
continued  their  present  amount  of  insurance,  there  would  remain  be- 
tween $40,000,000  and  $50,000,000  to  be  carried  in  State  or  local  funds 
establshed.  This  would  inevitably  lead  to  political  control  and  ]^imin^P- 
^jnent.     Payments  from  a  State  insurance  fund  and  its  operations  would 


1G6 

not  be  similar  to  the  expenditure  of  public  moneys  for  purposes  of 
government,  or  for  public  service,  or  for  the  construction  of  needed 
public  works.  Twenty  per  cent  of  the  wage-earners  would  be  entitled 
to  cash  payments  each  year  from  these  public  funds,  which  each  year 
would  be  lepienished  to  the  extent  of  $40,000,000. 

With  the  experience  of  doctois  frequently  asked  to  certify  falsely 
to  sickness  disability  under  present  insurance  contracts,  or  the  union 
expel lence  o±  sickness  claims  being  used  as  a  cover  for  unemployment, 
what  conlidence  could  be  had  in  a  politically  controlled  and  managed 
fund  of  such  piopoitions  with  no  practical  check  upon  its  disbursements 
annually  to  neaily  400,000  in  the  State? 

'I'he  honesty  or  integrity  of  public  administrators  is  not  in  question. 
Nevertheless  the  necessary  size  of  the  proposed  system,  the  difficulties   I 
attendant  upon  proper  administiation  and  the  probability  of  inadequate 
supervision  and  contiol  suggest  considerations  which  are  of  the  greatest 
irnportance. 

it  is  tiue,  of  course,  that  voluntary  health  insurance  in  Illinois  is 
not  standardized.  In  this  regard,  it  is,  however,  not  different  from 
many  forms  of  activity  with  respect  to  which  it  has  not  been  regarded  as 
necessary  to  interfere  with  the  freedom  of  contract  or  conduct  of  the 
individuals  concerned.  Voluntary  health  insurance,  ^  unlike  life  insur- 
ance, is  of  comparatively  recent  general  development.  It  is  to  be  ex- 
pected that  health  insurance  will  show  a  growth  and  tendency  toward 
standardization  as  the  importance  of  such  insurance  receives  more 
general  lecognition. 

Ceitam  of  the  methods  by  w^hich  the  sickness  hazard  is  insured 
agamsL  aie  of  compaiatively  recent  origin  and  during  the  short  period 
of  their  use  have  extended  rapidly.  The  recognition  of  the  importance 
of  health  insurance  is  glowing.  It  will  continue  to  grow.  More  and 
moie  of  the  waoje-earners  each  vear  will  be  insured. 

The  main  difficulty  at  the  present  time  is  the  unwillingness  of 
wage-earners  to  insure  because  of  the  lack  of  appreciation  of  the  relative 
importance  of  insurance  and  other  things.     Some  are  prudent;  some  are 
thrifty;  some  are  impiovident.     Few  could  not  pay  for  the  insurance  if  t 
they  desired  so  to  do.  •  *^ 

Society  does  not  consider  making  it  a  legal  requirement  that  the 
individual  «hall  each  pay-day  save  a  portion  of  his  earnings  to  provide 
against  the  almost  certainty  of  unemployment,  or  that  he  shall  have 
life  insurance  to  provide  against  the  certainty  of  death.     Not  until  the  -. 
freedom  of  the  individual  threatens  society  in  a  direct  and  immediate  / 
ay,  is  it  considered  a  sound  policy  to  compel  the  action  of  the  individual.  I 

Compulsion  by  law  has  freqeuntly  resulted  in  conduct  beneficial  to 
the  individual  when  considered  solely  as  a  physical  betterment.  But 
guardianship  by  government  of  the  normal  adult  man  or  woman  has 
sooner  or  later  either  ended  in  disaster  for  the  government  which  ^-^ 
tempted  it  or  in  the  servility  of  those  so  governed.  Hence,  unless^ 
Society  is  affected  in  an  important  w'ay,  the  conduct  of  the  individual 
should  be  determined  by  his  own  understanding  and  not  by  the  law  or 
government. 


167 

The  present  cost  of  voluntary  health  insurance  shows  an  element 
represented  by  the  costs  of  acquisition.  These  acquisition  costs  are 
incurred  in  the  writing  of  the  insurance;  when  voluntary  a  campaign 
of  education,  persuasion  and  good  salesmanship  are  necessary.  The 
application  of  the  principle  of  compulsion  would  decrease  very  materially 
the  costs  of  acquisition.  In  this  respect,  however,  insurance  is  not 
different  from  most  social  activity.  The  costs  involved  in  creating  a 
demand  for  or  an  appreciation  of  a  given  commodity  are  always  present, 
except  where  the  State  by  fiat  of  law  determines  that  the  individual 
shall  conduct  himself  in  a  manner  prescribed  by  law  and  shall  conform 
to  the  standard  thereby  established. 

It  is  the  opinion  of  the  Commission  that  its  findings  do  not  justify 
it  in  recommending  compulsory  health  insurance.  ^.   , 

11.  Occupational  Disease. 

The  subject  of  occupational  diseases  was  not  investigated  by  the 
Commission.  This  is  a  subject  requiring  special  knowledge  and  the 
service  of  experts  highly  specialized  and  trained.  Limitations  of  time 
and  money  and  the  inability  to  obtain  the  services  of  such  experts  during 
the  war  were  such  that  in  the  opinion  of  the  Commission  it  could  not 
conduct  an  investigation  of  occupational  disease  such  as  the  importance 
of  the  subject  requires. 

In  1911,  an  Illinois  Commission  on  Occupational  Disease  investi- 
gated and  reported.  That  Commission  indicated  that  the  subject  should 
have  further  study.  This  Commission  is  of  the  opinion  that  the  losses 
attendant  upon  occupational  diseases  should,  as  a  matter  of  fundamental 
principle,  be  paid  by  the  industry  causing  the  disease.  However,  the 
diseases  which  should  be  covered  and  the  method  by  which  payment 
should  be  made  constitute  an  important  and  difficult  probleni.  The  Com- 
mission is  of  the  opinion  that  the  Legislature  should  appoint  an  Occu- 
pational Disease  Commission  to  thoroughly  investigate  and  report  as  to 
the  proper  solution  of  this  problem. 

12.  The  Commission's  Recommendations. 

Brought  together,  the  Commission's  recommendations  are  as  follows : 

1.  That  the  authority  and  powers  of  the  State  Department  of  Public 
Health  be  enlarged  in  such  manner  as  to  give  this  Department  the 
direction  and  control  over  public  health  administration  in  the  State, 
including  the  administration  by  the  local  public  health  bodies  as  now 
constituted,  required  for  a  proper  coordination,  direction  and  control 
of  matters  pertaining  to  the  public  health. 

2.  That  the  County  Tuberculosis  Act  be  amended  so  as  to  provide 
for  payments  to  wage-earners  under  treatment  in  the  County  Tubercu- 
losis Sanatoria.     (A  suggested  bill  is  presented  as  "Exhibit  1.^') 

3.  That  the  Legislature  appropriate  the  sum  of  $60,000  for  the 
control  of  venereal  disease  in  accordance  with  the  program  therefor 
initiated  by  the  Federal  Government.  A  like  amount  will  thus  be  avail- 
able from  the  appropriation  by  Congress  for  this  purpose.  The  im- 
portance of  this  subject  is  such  as  to  indicate  the  desirability  of  the 


168 

Legislature's  appropriating  this  amount  which  is  the  maximum  to  which 
the  State  of  Illinois  could  be  entitled. from  the  Federal  appropriation. 
The  amount  of  the  Federal  appropriation  available  for  Illinois  will  be 
limited  by  the  amount  which  Illinois  appropriates. 

4.  That  a  Commission  be  created  to  study  the  problem  of  Occu- 
pational Diseases  and  the  methods  for  the  payment  of  compensation  for 
losses  occasioned  thereby. 

5.  That  a  Commission  be  created  to  study  and  investigate  the 
mortality  of  women  in  childbirth  and  of  infants  in  the  State;  facilities 
for  obstetrical  service;  and  such  other  matters  relating  to  pre-natal, 
obstetrical  and  post-natal  care  as  affect  the  health  and  well-being  of 
mothers  and  infants.     (A  suggested  bill  is  presented  as  "Exhibit  2.''.) 

6.  That  such  legislation  be  enacted  as  may  be  required  for  the 
establishment  of  a  county  hospital  in  each  county  of  the  State,  and  for 
the  provision  and  maintenance  of  diagnostic  facilities  tlierein  by  ^  the 
State. 

7.  That  such  steps  be  taken  as  may  be  necessary  to  provide  public 
health  nursing  service  in  each  county  of  the  State. 

It  seems  appropriate  at  this  place  to  call  attention  to  the  fact  that 
at  the  time  H.  A.  Millis  undertook  the  work  as  Secretary  for  the  Com- 
mission, at  his  request,  it  was  made  a  condition  of  his  so  doing  that  he 
should  not  participate  in  the  determination  or  formulation  of  the  con- 
clusions and  recommendations  of  the  Commission.  This  condition  has 
been  complied  with.  Mr.  Millis  has  not  been  present  at  any  of  the  meet- 
ings of  the  Commission  at  which  its  conclusions  and  recommendations 
have  been  determined. 

Mathhew  Woll,  a  member  of  the  Commission,  was  called  to  Washing- 
ton, D.  C,  in  September,  1918,  in  connection  with  work  which  required 
his  continuous  presence  there.  As  a  result,  he  has  not  participated  in 
the  determination  of  any  of  the  conclusions  or  recommendations  of  the 
Commission. 

w1lli4m   butterworth, 
Dr.  E.  B.  Coolley, 
Edna  L.  Foley, 
Mary  McEnerney, 
M.  J.  Wright, 
William  Beye,  Chairman. 

MINOEITY  EEPORT. 

The  undersigned  members  of  the  Commission  concur  in  all  the 
recommendations  made  by  the  majority  of  the  Commission  as  set  forth 
above  in  the  section  entitled,  "The  Commission's  Recommendations." 
Yet  we  feel  that  the  recommendations  made  fall  far  short  of  what  is 
called  for  by  the  facts  disclosed  by  the  Commission's  investigations. 
Moreover,  we  do  not  agree  with  the  majority  of  the  Commission  in 
their  conclusions  relative  to  compulsory  health  insurance's  set  forth 
under  the  caption  "Health  Insurance."  We  believe  that  the  results  of 
the  investigations   made  for  the   Commission   are   conclusive   evidence 


169 

of  the  need  for  a  system  of  compulsory  health  insurance  which  would 
be  applicable  to  practically  all  members  of  the  wage-earning  group, 
would  more  equitably  distribute  the  burden  of  the  costs  of  sickness  and 
would  make  more  adequate  provision  for  the,  medical  care  of  wage- 
earners  and  their  dependents  who  become  sick.  Consequently,  we  dis-- 
sent  from  the  conclusions  reached  by  the  majority  of  the  Commission 
tnat  '^It  is  the  opinion  of  the  Commission  that  its  findings  do  not  justify 
It  m  recommending  compulsory  health  insurance."  We  believe  that 
tnis  conclusion  of  the  majority  of  the  Commission  is  founded  on  an  m- 
aaequate  and  somewhat  misleading  interpretation  of  the  facts  dis- 
closed by  the  investigations  made  for  the  Commission.  We  set  fortli 
m  the  following  statements  what  we  believe  to  be  the  logical  conclusions 
to  be  drawn  from  these  facts  as  summarized  in  Chapters  I  to  IV  of  this 
report. 

1.  kSickness  is  a  serious  problem. — This  is  shown  by  its  extent, 
duration,  cost  and  its  economic  and  social  effects. 

^^a)  As  to  the  extent  of  sickness,  65.8  per  cent  of  the  3,048  fami- 
lies included  in  the  investigation  made  of  wage-earning  families  m 
Chicago  had  one  or  more  cases  of  serious  sickness  in  the  year.  In  571 
tamilies  serious  sickness  was  confined  to  wage-earners  or  members  other- 
wise gainfully  occupied;  in  543  families  a  gainfully  occupied  member 
and  one  or  more  dependents  were  sick;  in  891  families  the  sickness 
was  not  that  of  a  wage-earner.  Granted  that  the  families  investigated 
were  fairly  typical,  this  means  that  two  out  of  every  three  families  (65.8 
per  cent)  will  have  one  or  more  cases  of  serious  sickness  in  a  given  year. 
Jj^xpressed  in  another  way,  it  means  that  the  chances  are  two  to  one  that 
a  family  will  have  one  or  more  of  its  members  seriously  sick  in  a  given 
year.  Wage-earners  and  persons  otherwise  gainfully  occupied  were 
sick  in  1,114  or  36.5  per  cent  of  the  3,048  families.  This  means  that 
more  than  one  out  of  every  three  families  will  have  one  or  more  gain- 
fully occupied  members  ill  in  a  given  year.  Five  hlmdred  forty-three 
wage-earning  families  had  one  or  more  gainfully  occupied  and  one  oi- 
more  other  members  sick.     This  is  17.8  per  cent  of  all  the  families. 

(b)  The  problem  of  sickness  is  serious  because  of  the  time  loss  it 
entails. — In  Part  I,  Chapter  I,  attention  is  called  to  the  fact  that  if 
sickness  among  w^age-earners  were  spread  over  the  entire  working  popu- 
lation, it  would  produce  an  average  loss  of  approximately  nine  days  for 
eacli  wage-earner.  Assuming  that  this  is  correct,  the  fact  has  little 
significance  because  sickness  does  not  so  distribute  itself.  Nine-hundred- 
thirty-seven  or  20.9  per  cent  of  4,474  wage-earners  covered  by  the  Com- 
mission's family  investigations  lost  a  week  or  more  during  the  year  be- 
cause of  sickness.  The  average  time  loss  for  901  of  these  was  7.35 
weeks  each.  This  is  14.1  per  cent  of  a  year.  How  unevenly  this  loss 
of  working  time  is  distributed  is  seen  by  the  figures  taken  from  the 
benefit  associations  and  set  forth  in  Part  I,  Chapter  I.  These  figures 
show  that  of  those  disabled  for  more  than  seven  days,^  65  per  cent  will 
be  sick  for  less  than  four  weeks;  19  per  cent  from  four  to  eight  weeks; 
7  per  cent  from  eight  to  twelve  weeks ;  6  per  cent  from  twelve  to  twenty- 

1  In  the  investigation  made,  this  was  19.9  per  cent  of  the  number  exposed. 


mo 

seven  weeks;  3  per  cent  for  more  than  six  months;  and  1.29  ;per  cent 
for  more  than  a  year. 

(c)  21ie  cost  of  sickness  is  another  important  factor  in  determin- 
ing its  effect. — The  direct  losses  due  to  disabling  sickness  are  lost  wages 
and  costs  of  medical  service.  For  1,667  wage-earning  families  from 
which  the  Commission's  investigators  obtained  complete  data  as  to 
sickness  costs,  the  average  total  cost  of  illness  was  $97.98  per  family. 
This  represents  an  average  income  loss  of  7.5  per  cent.  The  cost  of 
sickness  as  well  as  the  incidence  of  sickness  was  found  to  be  highest  in 
the  group  with  lowest  incomes,  averaging  $107.33  in  families  whose 
incomes  for  the  year  were  not  more  than  the  equivalent  of  $850  for  a 
family  of  man,  wife  and  three  children  under  fifteen. 

(d)  Sickness  is  a  serious  problem  in  its  economic  and  social  effects — 
Two-hundred-ninety  or  16.7  per  cent  of  1,744  wage-earning  families 
in  which  there  was  sickness  (not  including  58  families  who  made  in- 
complete reports  as  to  income)  had  deficits  or  were  unable  to  meet  the 
year's  expenses  out  of  the  year's  income,  as  against  40  or  4.7  per  cent 
of  854  families  without  sickness  but .  having  deficits.  These  deficits 
were  met  in  various  ways.  Out  of  247  of  the  290  families,  35  received 
charity,  64  made  loans,  37  used  previous  savings,  104  left  bills  unpaid, 
32  used  money  from  insurance  and  14  met  the  deficits  in  other  ways. 
Deficits"  due  to  sickness  costs  would  have  been  considerably  greater  had 
not  many  of  the  families  been  recipients  of  free  medical  service.  Of 
1,909  families  reporting  sickness  costs,  298  or  15.6  per  cent  had  no 
medical  service  at  all  for  disabling  sickness  of  a  week  or  more  duration. 
Two-hundred-seventy-three  families  or  14.3  per  cent  had  the  free  service 
of  a  physician.  Thus  571  or  29.9  per  cent  of  these  families,  excluding 
those  who  obtained  treatment  in  hospitals  and  dispensaries,  either  went 
without  treatment  or  received  medical  service  as  a  charity.  One-hun- 
dred-ninety-eight or  10.4  per  cent  of  the  families  had  hospital  service 
for  which  they  paid.^  As  against  these  201  or  10.5  per  cent  had  free 
hospital  service.  Three-hundred-sixty-nine  families  or  19.3  per  cent 
secured  medical  treatment  in  dispensaries.  Though  some  of  these  dis- 
pensary patients  paid  small  admission  fees  and  fees  to  cover  costs  of 
medicines  and  appliances,  they  did  not  pay  for  medical  service.  The 
sum  of  the  families  who  received  free  medical  service  directly  from 
physicians  or  through  hospitals  and  dispensaries  is  843  or  44.1  per  cent 
of  the  total  number  of  families  considered.  Making  a  liberal  allowance 
for  duplication  in  the  obtaining  of  this  free  service,  one  is  fairly  accurate 
in  stating  that  40  per  cent  or  two  out  of  every  five  wage-earning  families 
who  had  disabling  sickness  of  a  week  or  more  duration  had  recourse 
to  medical  charity  sometime  during  the  year.  Of  the  1,909  families, 
213  or  11.2  per  cent  had  nursing  service  from  either  a  private  duty 
nurse  or  a  visiting  nurse;  42.8  per  cent  paid  in  part  or  in  full  for  this 
service  and  57.2  per  cent  received  it  free. 

2.  Sickness  is  a  problem  calling  for  the  application  of  the  insur-  ' 
ance  principle. — Insurance  is  cooperative  provision  against  individual 
losses.     Sickness  is  a  risk  to  which  every  individual  is  exposed.     In- 

2  This  may  or  may  not  have  included  payment  for  physicians'  services. 


171 

surance  is  a  means  of  distributing  losses.  The  losses  due  to  sickness, 
if  distributed  over  the  entire  wage-earning  group  and  paid  in  weekly, 
semi-monthly  or  monthly  installments,  would  not  fall  heavily  upon  any 
one  individual,  while  on  the  other  hand  individual  or  family  sickness 
costs  frequently  cause  substantial  deficits,  lowered  standards  of  living 
and  other  unfavorable  results.  The  incidence  of  sickness  in  any  con- 
siderable group  is  so  constant  as  to  make  the  risk  insurable  on  a  sound 
actuarial  basis. 

3.  That  sickness  is  an  insurable  risk  is  generally  recognized — 
Evidence  of  this  is  seen  in  the  number  and  variety  of  organizations  pro- 
viding some  form  of  health  insurance.  In  Illinois  such  insurance  is 
provided  by  numerous  establishment  funds,  trade  unions,  fraternal 
societies,  independent  foreign  benefit  societies,  casualty  companies,  and 
assessment  associations. 

4.  In  spite  of  the  fact  that  there  is  this  great  variety  of  carriers  in 
the  State,  the  great  majority  of  ivage-earners  have  no  health  insurance — 
The  Commission's  study  of  wage-earning  families  in  Chicago  shows  that 
of  4,456  wage-earners,  1,055  or  23.7  per  cent  carried  some  form  of  dis- 
ability insurance.  Of  wage-earning  husbands  the  percentage  carrying 
disability  insurance  was  36.7.  Thus  over  three-fourths  of  the  wage- 
earners  studied  did  not  report  themselves  as  protected  by  insurance 
against  sickness  risks.  It  was  found,  moreover,  that  the  families  in  the 
lowest  income  group  had  the  least  health  insurance.  Our  investigations 
show  that  only  about  30  per  cent  of  wage-earners  in  Illinois  have  health 
insurance  of  any  sort  and  that  of  wage-earning  families  in  Chicago 
there  is  even  a  smaller  percentage,  namely  23.7. 

5.  Much  of  the  health  insurance  carried  by  wage-earners  is  inade- 
quate and  costly. — Information  obtained  by  the  Commission's  investi- 
gators leads  to  the  following  conclusions  relative  to  the  disability  benefits 
received  from  the  various  sickness  insurance  carriers : 

(a)  That  though  20.9  per  cent  or  4,474  wage-earners  lost  wages 
for  a  week  or  more  during  the  year,  only  13.4  per  cent  of  these  received 
benefits  partially  indemnifying  them  for  such  loss. 

(b)  That  the  average  loss  was  $118.76  and  that  the  average  benefit  . 
received  was  $52.44  or  but  44.1  per  cent  of  the  insured  wage-earner's 
'loss. 

(c)  That  taking  the  group  as  a  whole,  the  disability  insurance 
received  was  only  about  6  per  cent  of  the  wage  loss  caused  by  disabling 
sickness  of  a  week  or  more  in  duration. 

(d)  That  not  only  was  there  most  sickness  and  a  greater  average 
wage  loss  in  the  lowest  income  group  but  that  the  average  benefit  was 
lowest  in  the  same  group,  being  but  15.5  per  cent  of  the  wages  lost  as 
compared  with  43.1  per  cent  and  47.4  per  cent  respectively  in  the  two 
higher  income  groups. 

With  the  exception  of  a  limited  number  of  establishment  funds,  the 
whole  cost  of  such  insurance  is  borne  by  the  wage-earner.  It  is  our 
opinion  that  industry  and  the  community  are  partly  responsible  for  the 
losses  sustained  and  should  make  contribution  to  the  funds  needed  to 
cover  them.     Certainly  such  facts  as  are  cited  or  referred  to  in  section 


172 

7  of  Chapter  I  of  this  report  leave  no  reasonable  doubt  as  to  the  responsi- 
bility of  industry  and  the  community  for  much  of  the  illness  among 
wage-earners  and  their  families.  Moreover,  it  cannot  be  denied  that 
both  industry  and  the  community  as  a  whole  would  benefit  materially 
from  any  substantial  improvement  in  the  situation  which  obtains,  whether 
in  a  reduction  in  amount  of  sickness  and.  impaired  efficiency  or  in  a 
lessened  feeling  of  discontent. 

Health  insurance  provided  by  casualty  companies  is  very  expensive, 
as  shown  by  the  fact  that  less  than  half  of  the  money  paid  in  as  premiums 
is  paid  out  in  cash  benefits  to  the  sick. 

6.  Most  of  the  health  insurance  carried  by  wage-earners  in  Illinois 
provides  p/artial  indemnity  for  lost  wages  only. — It  falls  short  of  the  de- 
sirable in  that  little  of  it  includes  any  provisions  for  medical  service. 

7.  There  is  distinct  need  for  a  better  organization  of  medical  service 
for  wage-earners. — It  is  an  indisputable  fact  that  the  well-to-do  (outside 
of  the  wage-earning  class)  and  those  who  have  recourse  to  medical 
charity  receive  the  best  medical  service.  The  fact  that  about  40  per 
cent  of  wage-earning  families  in  Chicago,  covered  by  our  investigations, 
had  recourse  to  free  medical  service  in  a  vear  reveals  a  condition  which 
is  unfair  to  both  the  wage-earners  and  the  medical  profession. 

8.  //  the  application  of  the  insurance  principle  to  the  problem  of 
sickness  among  wage-earners  and  their  dependents  is  to  be  most  effective 
it  must  be  universal. — All  experience  shows  that  if  such  insurance  is  to 
be  extended  ip  more  than  a  mere  fraction  of  the  wage-earners,  it  must 
be  compulsory. 

We  believe  that  the  above  analysis  of  the  facts  disclosed  by  the  in- 
vestigations made  for  the  Commission  is  the  only  logical  interpretation 
of  these  facts  and  would  have  justified  the  Commission  in  recommending 
the  immediate  adoption  of  compulsory  health  insurance  in  Illinois.  In 
our  opinion  cash  benefits  partially  indemnifying  the  loss  of  wages  and  the 
provision  of  medical  care  for  Avage-earners  and  their  dependents  would 
be  of  great  value.  We  see  no  reason  why  the  organization  of  medical 
practice  under  compulsory  health  insurance  could  not  be  so  effected  as 
to  promote  the  interests  of  the  insured,  the  medical  profession  and  the 
community  as  a  whole.  When  health  insurance  is  made  compulsory  all 
experience  shows  that  most  of  it  will  be  carried  by  such  organization^ 
as  those  in  which  a  minority  are  now  insured  and  which  will  become 
standardized  in  order  to  qualify  as  carriers.  It  would  perhaps  be  neces- 
sary to  establish  local  mutual  organizations  for  those  who  could  not  or 
would  not  join  existing  organizations,  but  what  basis  is  there  for  assum- 
ing that  these  would  be  politically  controlled?  In  view  of  the  fact  that 
the  officials  of  these  organizations  would  be  elected  by  those  who  con- 
tribute to  the  funds,  it  seems  to  us  that  the  assumption  contained  in  the 
majority  report  that  they  would  be  so  controlled  is  gratuitous. 

With  reference  to  the  point  made  in  the  majority  report  that  com- 
pulsory health  insurance  has  not  been  an  important  factor  in  the  pre- 
vention of  sickness,  we  would  not  claim  thgifcompulsory  health  insurance 
is  intended  as  a  preventive  medical  measure.  Like  many  other  forms  of 
insurance  it  is  not  intended  to  eradicate  the  risk  against  which  it  offers 


173 

protection.  We  would  call  attention,  however,  to  the  fact  that  the 
British  Medical  Society  has  expressed  the  opinion  that  the  medical  care 
of  English  wage-earners  has  been  materially  improved  under  compulsory 
health  insurance.  Grood  medical  care  prevents  much  disabling  sickness. 
Moreover,  insurance  supported  in  part  by  industry  and  the  public  may 
arouse  a  greater  interest  in  the  prevention  of  disease. 

Alice  Hamilton,  M.  D. 

John  E.  Ransom. 

EXHIBIT  I. 

A  Bill  For 

AN  ACT  to  amend  the  title  of  and  an  Act  entitled,  ''An  Act  to  author- 
ize county  authorities  to  establish  and  maintain  a  County  Tuberculosis 
Sanitorium,  and  branches,  dispensaries  and  other  auxiliary  institutions 
connected  with  the  same,  and  to  levy  and  collect  a  tax  to  pay  the  cost 
of  their  establishment  and  maintenance/'  approved  June  28,  1915,  in 
force  July  1,  1915. 

Section  1.  Be  it  Enacted  by  the  People  of  the  State  of  Illinois, 
represented  in  the  General  Assembly:  That  the  title  of  an  Act  entitled,. 
•'An  Act  to  authorize  county  authorities  to  establish  and  maintain 
a  County  Tuberculosis  Sanitorium,  and  branches,  dispensaries  and  othei 
auxiliary  institutions  connected  with  the  same,  and  to  levy  and  collect 
a  tax  to  pay  the  cost  of  their  establishment  and  maintenance,^'  approved 
June  28,  1915,  in  force  July  1,  1915,  be  amended  so  as  to  read,  "An 
x4ct  to  authorize  county  authorities  to  establish  and  maintain  a  Count}' 
Tuberculosis  Sanitorium,  and  branches,  dispensaries  and  other  auxiliar} 
institutions  connected  with  the  same,  and  to  levy  and  collect  a  tax  to 
pay  the  cost  of  their  establishment  and  maintenance,  and  to  provide  for 
the  partial  support  of  those  dependent  upon  those  who  are  under  treat- 
ment in  a  County  Tuberculosis  Sanitorium  and  the  levy  and  collection 
of  a  tax  to  pay  the  cost  thereof ;"  and  that  said  Act  be  amended  by  add- 
ing thereto  a  new  section,  to  be  known  as  Section  7%,  to  read  as  follows^ 

Sec.  7I/2  (1)  A  county  in  which  there  is  established  and  main- 
tained under  this  Act,  a  County  Tuberculosis  Sanitorium,  shall  pay  semi- 
monthly to  each  one  who  is  confined  in  the  Sanitorium  and  is  therein 
receiving  treatment  for  tuberculosis,  an  amount  equal  to  one-twenty- 
fourth  (l/24th)  of  his  earnings  for  the  year  preceding  his  entrance  into 
aaid  Sanitorium,  subject  to  the  following  conditions : 

(a)  Payment  shall  be  made  only  to  one  who  was  a  resident  of  the 
county  for  one  year  previous  to  his  entrance  into  the  Sanitorium,  and 
upon  whom,  at  the  time  of  entrance  therein,  a  wife  or  child  was  depend- 
ent for  support. 

(b)  Any  semi-monthly  payment  to  any  person  shall  not  exceed  the 
amount  of  Thirty  Dollars. 

(c)  Semi-monthly  payments  to  any  person  shall  not  continue  be- 
yond two  years  from  the  time  of  the  first  payment. 

(d)  Payment  shall  be  made  only  after  the  issuance  of  a  certificate 
in  accordance  with  the  rules  prescribed  by  the  Sanitorium  Board  of 


174 

Directors,  showing  that  the  one  to  receive  the  payment  has  been  under 
treatment  in  the  Sanitorium  during  the  period  covered  by  the  payment, 
and  has  conformed  to  all  the  rules  and  regulations  of  the  Sanitorium. 

(2)  A  county  which  makes  provision  for  the  treatment  of  those  who 
are  tubercular  by  arrangements  with  another  count)^  which  maintains 
a  County  Tuberculosis  Sanitorium,  under  the  provisions  of  this  Act,  shall 
make  semi-monthly  payments  to  the  residents  of  the  first  mentioned 
county  whose  treatment  is  provided  for,  which  payment  shall  be  made 
in  the  same  manner  as  provided  in  this  section  for  counties  which  main- 
tain a  County  Tuberculosis  Sanitorium. 

(3)  To  provde  for  the  payments  as  required  by  this  section,  a  tax 
shall  be  levied  and  collected  by  the  county  in  the  manner  provided  for 
the  levying  and  collection  of  taxes  for  county  purposes,  which  said  tax 
shall  be  in  addition  to  all  other  taxes  which  said  county  is  now  or  here- 
after may  be  authorized  to  levy  on  the  aggregate  value  of  all  property 
within  said  county,  and  in  reducing  tax  levies  under  the  provisions  of 
Section  2  of  an  Act  entitled,  "An  Act  to  amend  Section  2  of  an  Act 
entitled,  ^An  Act  concerning  the  levy  and  extension  of  taxes,'  approved 
May  9,  1901,  in  force  July  1,  1901,  and  as  subsequently  amended,  the  tax 
authorized  by  this  section  shall  not  be  considered  as  a  part  of  the  general 
tax  levy  for  county  purposes,  and  the  same  shall  not  be  included  in  the 
limitation  of  the  assessed  valuation  upon  which  taxes  are  required  to  be 
extended,  as  provided  in  said  Act  as  subsequently  amended. 

EXHIBIT  2. 

COMMISSION    TO    INVESTIGATE    CONDITIONS    CAUSING    MATERNAL.    AND 

INFANT  MORTALITY. 

§  1.     Creation  and  Duty. 

§  2.     Members. 

§  3.     Powers. 

A  Bill  For 

AN  ACT  to  establish  a  commission  to  investigate  conditions  causing  ma- 
ternal and  infant  mortality  and  the  facilities  for  providing  care  for 
women  in  childbirth. 

Section  1.  Creation  and  duty.]  Be  it  enacted  by  the  People  of 
the  State  of  Illinois  represented  in  the  General  Assembly:  'J^hat  a 
special  commission  is  hereby  created  to  be  known  as  the  Maternal  and 
Infant  Welfare  Commission  which  shall  investigate  conditions  causing 
death  and  disability  of  women  from  childbirth  and  conditions  incident 
thereto  and  of  infants.  It  shall  investigate  the  facilities  for  the  provision 
of  prenatal,  obstetrical  and  post-natal  care,  and  other  conditions  which 
effect  the  health  and  well-being  of  mothers  and  infants  in  the  State. 
The  Commission  shall  hold  public  hearings  in  different  parts  of  the 
State.  The  Commission  shall  submit  a  full  final  report,  including  such 
recommendations  for  legislation  by  bill  or  otherwise  as  in  its  judgment 
may  seem  proper,  to  the  General  Assembly  of  nineteen  hundred  and 


§   4.     Cooperation  of  other  Departments. 
§  5.     Appropriation. 


175 

twenty-one  and  unless  continued  by  such  General  Assembly,  shall  expire 
at  the  end  of  its  regular  session. 

Seo.  2.  Members.]  The  Commission  shall  consist  of  two  physicians, 
one  nurse^,  one  social  worker,  one  hospital  superintendent  and  two  other 
persons  to  be  appointed  by  the  Governor.  The  members  of  such  com- 
mission shall  receive  no  compensation  for  their  services,  but  shall  be 
entitled  to  their  actual  and  necessary  expenses  incurred  in  the  perform- 
ance of  their  duties. 

Seo.  3.  Powers.]  The  Commission  shall  have  power  to  elect  its 
chairman  and  other  officers,  to  employ  a  secretary,  experts  in  the  matters 
to  be  investigated,  and  all  necessary  clerical  and  other  assistants,  to 
purchase  books  and  all  necessary  supplies,  and  to  rent  office  room,  and 
halls  for  hearings. 

Sec.  4.  Cooperation  of  other  departments.]  The  Department 
of  Public  Health,  the  Department  of  Public  Welfare  and  the  Department 
of  Eegistration  and  Education  are  hereby  directed  to  cooperate  with  the 
commission,  to  give  it  access  to  their  records,  and  to  render  it  any  such 
proper  aid  and  assistance  as  in  their  judgment  may  not  interfere  with  the 
proper  conduct  of  their  respective  departments. 

Sec.  5.  Appropriation.]  The  sum  of  twenty-five  thousand  ($25,- 
000)  dollars  or  so  much  thereof  as  may  be  needed,  is  hereby  appro- 
priated for  the  actual  and  necessary  expenses  of  the  commission  in 
carrying  out  the  provisions  of  this  Act,  and  the  Auditor  of  Public  Ac- 
counts is  hereby  authorized  to  draw  his  warrant  for  the  foregoing  amount, 
or  any  part  thereof,  in  payment  of  any  expense,  charges,  or  disbursements 
authorized  by  this  Act  on  order  of  the  commission,  signed  by  its  chair* 
man,  attested  by  its  secretary,  and  approved  by  the  Governor. 


PART  II 


Reports  of  Special  Investigations 


-12  H  I 


179 


SPECIAL  REPORT  I.     A  STUDY  OF  WAGE-EARNING 

FAMILIES  IN  CHICAGO. 

(By  Ernest  W.  Burgess.) 


[Note -by  the  Secretary. — In  order  to  secure  exact  data  bearing  upon  the  many 
phases  of  the  problems  under  investigation,  the  Commission  has  had  an  intensive 
study  made  of  a  limited  number  of  wage-earning  families.  The  funds  and  staff 
available  for  investigation  did  not  permit  extending  the  study  to  communities  out- 
side of  Chicago.  The  secretary  had  the  assistance  of  several  experts  in  preparing 
for  this  intensive  study.  Among  these  was  Dr.  E.  W.  Burgess  who  was  later  in- 
duced to  take  immediate  charge  of  this  branch  of  the  investigation.  He  has  inter- 
preted the  data  and  prepared  the  following  report]. 

I.  INTEODUCTIDN. 

The  Family  Study  was  undertaken  by  the  Comn^ission  to  obtain 
data  bearing  upon  sickness,  medical  service,  and  protection  against  health 
risks.  The  points  ^poh  which  information  was  desired  were  numerous : 
the  extent  and  the  duration  ofdllness,  sickness  costs,  the  nature  and 
kinds  of  medical  treatment,  the  extent  and  amount  of  insurance  against 
sickness  and  death,  variation  in  sickness  and  insurance  by  sex,  age, 
nationality  and  economic  condition,  and  the  relation  of  sickness  to 
poverty  and  to  dependency. 

This  introduction  presents :  first,  an  outline  of  the  divisions  of  the 
study  made;  secondly,  a  description  of  the  methods  of  investigation  and 
tabulation;  thirdly,  a  general  classification  of  the  families  studied; 
fourthly,  a  statement  of  the  method  of  determining  "economic  status;" 
and  fifthly,  an  analysis  of  the  population  and  income  statistics  for  the 
families  studied. 

(1)   Divisions  of  the  Family  Study. 

Families  were  selected  in  three  ways  so  that  the  Family  Study  falls 
into  three  parts:  the  block  study;  the  nursing  service  study;  and  the 
charity  study. 

The  hloch  study. — Since  proposed  systems  of  health  insurance  have 
as  their  objective  the  protection  of  wage-earners  and  their  families  from 
the  risk  of  sickness  and  non-industrial  accident,  it  was  considered  ad- 
visable by  the  Commission  to  secure  from  a  representative  group  of 
independent  wage-earners  data  relating  to  sickness,  to  existing:  Tnethods 
of  conserving  health,  and  to  insurance  and  other  methods  designed  to 
meet  the  risks  of  sickness  and  death.  Two  alternatives  were  possible. 
One  was  to  visit  at  random  families  throughout  the  city,  the  other  to 
canvass  every  family  living  in  certain  blocks  representative  of  the  group 
of  wage-earners  in  Chicago.  The  second  plan  was  adopted  because  of 
the  greater  opportunity  for  the  control  of  the  selection  of  families  and 
for  the  verification  of  the  results  secured. 


180 

Instead  of  the  geographical  block  the  social  block  was  made  the  unit 
of  investigation.  By  social  block  is  meant  the  two  sides  of  a  residential 
street.  Social  and  civic  workers  recognize  that  the  social  block  repre- 
sents a  natural  social  group  and  that  the  alley  is  a  line  of  separation 
rather  than  of  connection  between  families. 

The  blocks  studied  were  carefully  chosen  in  order  to  be  represent' 
ative  of  Chicago's  wage-earning  population.  The  investigations  made 
by  the  School  of  Civics  and  Philanthropy  into  housing  conditions  in 
Chicago  were  utilized  in  the  selection  of  blocks  with  known  differences 
in  physical  structure,  racial  composition  and  economic  condition.  So 
far  as  possible  a  normal  distribution  of  the  different  immigrant  and 
racial  grouj)s  in  Chicago  was  provided  for.  An  attempt  was  also  made 
to  secure  adequate  representation  of  all  degrees  of  economic  condition 
from  casual  laborer  to  the  skilled  workman.  The  location  of  blocks 
with  reference  to  dispensaries,  hospitals  and  other  welfare  agencies  was 
given  special  attention,  and  their  geographical  position  in  relation  to  the 
chief  industries  of  the  city  w^as  taken  into  account.  In  addition  to  fill- 
ing out  a  schedule  for  each  family,  the  investigator  was  required  to  write 
a  statement  to  cover  each  block,  indicating  the  typical  facts  of  its  physical 
structure,  its  racial  composition,  the  economic  status  of  its  families, 
the  range  of  rents  paid,  accessibility  to  medical,  charitable  and  welfare 
institutions,  the  attitude  of  its  resideAts  to  medical  and  social  agencies 
and  in  addition  other  facts  significant  for  the  study. 

The  rmirsing  service  study. — The  304  families  included  in  the  survey 
of  the  Visiting  Nurse  Association  cases  were  chosen  by  that  organization. 
They  are  representative  not  only  of  the  families  which  come  under  the 
care  of  this  Association  but  also  of  the  problems  involved  in  the  medical 
service  secured.  Inasmuch  as  all  of  the  investigators  for  the  .Com- 
mission in  this  study  were  themselves  registered  nurses  at  the  time  or 
previously  on  the  staff  of  the  Association  and  consulted  the  case  records 
of  the  organization  in  addition  to  visiting  the  families,  the  data  secured 
are  of  peculiar  value  from  the  standpoint  of  the  sickness  problem  and 
medical  and  nursing  service. 

Tli&  charity  study. — Through  the  cooperation  of  the  United  Chari- 
ties and  the  Jewish  Aid  Society  1,000  families  were  selected  where  sick- 
ness of  a  wage-earner  or  other  member  of  the  family  was  considered  as 
a  problem  entering  into  dependency.  The  majority  of  these  cases  were 
"current,"  i.  e.  the  families  were  still  receiving  material  relief  or  super- 
vision from  the  organizations.  A  considerable  number  were  "closed" 
cases,  i.  e.  families  which  a  short  time  previously  had  been  receiving 
charitable  aid  but  which  were  now  again  independent  and  no  longer 
under  the  care  of  the  social  agency.  These  families  were  selected  in  the 
months  of  May  and  June,  a  period  in  which  there  are  relatively  few 
new  cases  coming  to  the  attention  of  charitable  organizations.  It  is 
therefore  probable  that  in  spite  of  the  fact  that  a  considerable  number 
of  "closed"  case^  were  included  in  the  group,  the  families  selected  would 
not  altogether  represent  the  correct  proportion  of  the  different  types  of 
families  seeking  charity  during  the  year.  From  the  1,000  cases  selected 
by  the  charities,  schedules  for  628  families  were  finally  available  for  use 


181 

in  the  study.  The  remaining  372  cases  represent  families  that  had 
moved,  families  that  had  disintegrated  and  families  where  acceptably 
complete  information  could  not  be  secured. 

It  is  evident  despite  much  in  common  tliat  the  three  studies  have 
three  distinct  purposes.  The  block  study  bears  upon  the  problem  of 
sickness  and  the  existing  protection  against  illness  from  the  standpoint 
of  the  independent  wage-earner.  The  nursing  service  survey  provides 
the  basis  for  an  inquiry  into  the  relation  between  medical  and  nursing 
service  and  the  particular  kind  of  disabling  sickness.  The  charity 
study  makes  possible  an  analysis  of  disabling  sickness  in  its  relation  to 
the  problems  of  poverty  and  dependency. 

(2)  Methods  of  Investigation  Employed. 

The  schedule  used  in  the  Family  Study  was  common  to  the  three 
divisions  of  the  investigation'  It  was  developed  after  an  examination 
of  schedules  used  in  family  studies  in  different  sections  of  the  country 
and  with  the  assistance  of  several  persons  who  are  expert  on  the  points 
covered  in  the  study.  It  was  first  used  in  mimeographed  form  and  then 
revised  in  the  light  of  the  experience  gained  in  this  way.  The  schedule 
form  and  the  instructions  issued  to  the  investigators  for  the  Commission 
are  printed  as  an  appendix  to  this  report.^  In  addition  to  the  usual 
inquiries  in  regard  to  name,  address,  nationality,  housing  conditions  and 
rent,  the  items  of  the  schedule  center  about  family  composition;  em- 
ployment,  income,  surplus  and.  deficit;  value  of  property  owned;  the 
sickness  history  of  every  member  of  the  family  during  the  last  twelve 
months ;  the  dispensary  record  for  all  members  of  the  family  during  the 
last  twelve  months;  provision,  need  and  cost  of  dental  v/ork;  the  amount 
and  type  of  life  and  disability  insurance  carried  by  members  of  the 
family;  deaths  in  the  family  during  the  year  and  cost  of  burial;  births 
in  family  during  the  year;  the  employment  of  physician  or  mid-wife; 
and  the  cost  of  nursing  care  and  hospital  service.  A  most  valuable  part 
of  the  schedule  was  the  page  assigned  to  a  history  of  the  family  known 
as  -  the  "story"  in  which  were  entered  significant  facts  not  otherwise 
specifically  called  for,  as,  for  example,  the  sickness  experience  of  the 
family  during  a  period  of  years,  their  attitude  towards  physicians,  dis- 
pensaries and  social  agencies,  changes  in  the  standard  of  living  during 
the  year  due  to  sickness,  complete  charity  record,  etc. 

The  agents  employed  in  making  the  block  study  were  selected  on  the 
basis  of  background  of  social  training,  experience  and  success  in  social 
investigation,  and  command  of  language  of  the  chief  immigrant  groups 
in  Chicago.  Advanced  students  in  economics  and  sociology  at  the  Uni- 
versity of  Chicago  and  at  the  Chicago  School  of  Civics  and  Philanthropy 
undertook  the  charity  study  for  the  Commission  as  field  work  in  con- 
nection with  classes  in  sociology,  social  work,  and  labor  problems.  By 
special  arrangement  with  the  Visiting  In]  urse  Association  the  Commission 
was  able  to  secure  the  services  of  registered  nurses  in  making  the  nursing 
service  study.  Nearly  all  of  the  schedules  in  the  block  study  were 
collected  by  four  experienced  investigators,  on  salary. 

^  See  pp.   313-17. 


182 

To  each  investigator  was  issued  a  card  of  indentification  certifying 
to  his  appointment  as  an  agent  of  the  Commission.  This  was  signed 
by  tne  cnaiiman  of  the  Commission  and  countersigned  by  the  Governor 
of  the  KState.  Mimeogiaphed  instiuctions  covering  in  detail  the  items 
of  the  fccliedule  weie  given  to  each  investigator.  Before  going  into  the 
held  a  conteience  of  agents  was  held  for  a  careful  and  detailed  inter- 
piCtation  of  the  schedule  and  for  oral  instiuction  in  regard  to  methods 
of  appioacli  and  the  tecnnique  of  investigation.  In  practically  all  cases 
inexperienced  mvestigatois  weie  given  demonstration  and  supervision 
m  tne  field  by  supervisors  for  the  Commission.  Charity  cases  were 
fiist  assigned  to  investigators,  because  of  the  greater  difficulty  in  ap- 
pioachmg  the  families  of  independent  wage-earners  for  the  information 
desired.  The  visitois  were  instructed  to  state  at  once  to  the  prospective 
informant  the  puipose  of  their  visit  and  the  object  of  the  investigation 
so  that  they  might  secure  the  intelligent  cooperation  of  the  family  in 
making  out  the  schedule.  Schedules  filled  out  in  the  field  were  promptly 
edited  for  conference  with  the  investigators  in  regard  to  the  correction 
of  inaccurate  or  incomplete  entries.  Less  than  one  hundred  schedules 
were  discarded  because  of  inaccurate  or  incomplete  data  secured  by 
some  of  the  student  investigators. 

Univeisal  interest  in  the  problem  of  sickness  and  the  fact  that  the 
investigation  was  undertaken  under  the  authority  of  the  State  of  Illinois 
were  piobably  the  chief  reasons  for  the  full  and  relatively  accurate  re- 
turns secured  by  the  investigators.  Less  than  a  score  of  over  4,000 
families  visited  refused  to  give  information.  What  inaccuracies  and 
omissions  appear  in  the  answers  to  specific  questions  are  due  more  to  the 
inability  than  any  unwillingness  of  families  to  give  complete  and  detailed 
answers  to  these  inquiries.  For  example,  of  the  2,708  wage-earning 
families  in  our  "block  study'^  only  110  gave  incomplete  reports  of  total 
family  income,  an  entry  considered  one  of  the  most  difficult  to  secure. 
Sometimes  the  wife  did  not  know  the  exact  amount  of  the  husband's 
earnings.  Occasionally,  as  with  casual  work,  or  with  change  of  em- 
ployment, during  the  year,  or  with  loss  of  wages  and  time  because  of 
sickness  and  employment,  it  was  practically  impossible  for  the  housewife 
to  state  either  average  earnings  per  week,  or  total  earnings  received  dur- 
ing the  last  twelve  months.  The  rise  in  wages  during  the  year,  partic- 
ularly in  the  Stock  Yards  and  South  Chicago  areas,  added  to  the  difficulty 
of  determining  the  total  income  for  the  year.  In  a  few  cases,  chiefly,  how 
ever,  with  families  where  the  nonnal  breadwinner  was  working  on  his  own 
account,  wives  felt  that  the  inquiry  was  too  personal  and  so  were  disin- 
clined even  when  they  knew  the  income  to  give  a  definite  answer.  The 
amount  of  deficit  was  discovered  without  difficulty  sooner  or  later  in  the 
investigation.  As  one  of  the  agents  of  the  Commission  states,  "if  the 
informant  denied  it  at  first  she  would  usually  ^come  out'  with  it  in 
emphasizing  a  big  doctor's  bill  or  the  high  cost  of  living  or  some  other 
grievance."  The  returns  on  surplus  are  probably  the  most  unsatis- 
factory of  the  answers  to  any  item.  Only  Liberty  Bonds — and  in  many 
families  their  presence  brought  the  first  surplus  in  years — were  readily 
and  patriotically  admitted.     While  families  were  willing  to  state  whether 


183 

they  came  out  even  or  ahead,  they  were  not  inclined  to  state  definitely 
the  amount  of  the  family  surplus  and  to  give  necessary  detail  required 
to  check  it. 

It  was  surprising  how  definite,  in  most  instances,  was  the  knowl- 
edge of  a  family  of  most  of  the  details  connected  with  sickness.  In 
the  case  of  certain  immigrant  groups  (the  Italian,  for  example),  how- 
ever, an  understanding  of  the  ailment  was  generally  limited  to  the  part 
of  the  body  affected.  In  the  charity  group  the  records  of  the  United 
Charities  and  the  Jewish  Aid  Society  contained  in  practically  every 
case  the  doctor^s  diagnosis.  In  the  group  of  families  from  the  Visiting 
Nurse  Association  the  record  given  by  the  investigator  was  unusually 
definite  and  accurate.  The  items  of  cost  of  sickness,  doctor's  and 
hospital  bills  are,  it  is  believed,  quite  correct  because  of  the  attention  in 
the  family  economy  which  is  given  to  these  unforeseen  expenditures. 
This  statement  applies  also  to  cost  of  dental  work.  The  cost  of  medicine 
can,  however,  be  regarded  as  only  a  tolerably  close  approximation. 
Moreover,  small  outlays  for  medicines  were  probably  not  reported  in 
a  considerable  number  of  cases.  Dispensary  entries,  as  found  by  com- 
parison with  original  records  at  the  dispensaries,  were  quite  satisfactory 
for  all  items  except  the  nature  of  ailment.  Information  in  regard  to 
life  and  industrial  insurance  was  easily  obtained,  first  because  the  house- 
wife herself  generally  had  charge  of  this  matter,  and,  secondly,  because 
she  was  always  proud  to  tell  about  it.  The  weekly  premium  of  in- 
dustrial policies  was  found  to  be  more  accurate  than  the  amount  of 
insurance  carried.  The  amount,  however,  was  computed  from  the 
premiums  with  the  assistance  of  the  resident  officers  of  the  Metro- 
politan Life  Insurance  Company.  Less  definite  was  the  knowledge  of 
the  wife  of  the  benefit  features  of  the  trade  union  to  which  her  husband 
belonged,  or  of  the  establishment  fund  in  which  he  was  a  participant. 
Only  in  case  of  sickness  of  wage-earner  during  the  year  was  information 
likely  to  be  complete  on  these  items.  The  amount  of  insurance  of  all 
kinds  received  during  the  year  was  given  accurately  and  in  detail.  The 
data  as  returned  for  inquiries  concerning  maternity  were  highly  satis- 
factory. 

The  Commission  availed  itself  of  every  opportunity  to  verify  and  to 
correct  the  data  secured  by  its  agents  in  the  field.  The  leading  welfare 
agencies  in  Chicago  maintain  more  or  less  complete  records  of  all  the 
families  they  serve.  Practically  all  of  the  more  important  social 
agencies  register  their  cases  either  with  the  Social  Service  Registration 
Bureau  or  with  the  Central  Bureau  of  the  Jewish  Charities.  Agents  for 
the  Commission  cleared  all  the  schedules  collected  in  the  family  study 
through  these  two  registration  bureaus.  Through  the  cooperation  of  the 
Cook  County  Agent  all  schedules  were  also  cleared  through  his  branch 
offices  in  order  to  verify  the  statement  of  the  family  of  the  fact  of  aid 
received  and  to  determine  the  exact  value  in  money  of  the  monthly 
supplies  issued.  So  far  as  the  records  made  it  feasible,  all  cases  were  also 
cleared  through  the  different  dispensaries  of  Chicago.  The  Municipal 
Tuberculosis  Sanitarium  gave  valuable  assistance  to  the  Commission  by 
reporting  the  exact  medical  diagnosis  in  all  tuberculous  cases  recorded 


184 

by  it.  It  should  also  be  restated  here  that  the  records  of  the  United 
Charities  and  of  the  Jewish  Aid  Society  had  been  consulted  by  the  agents 
for  the  Commission  prior  to  their  visit  to  the  families.  In  addition  to 
the  obvious  value  of  this  pooling  of  all  accessible  data  by  clearing  all 
cases  through  the  different  medical  and  charitable  agencies  of  the  city, 
two  significant  conclusions  were  derived.  The  first  was  the  general 
confirmation  of  the  completeness  and  the  accuracy  of  the  information 
obtained  by  the  investigators  for  the  Commission.  Only  in  relatively 
few  cases  were  there  serious  omissions  or  discrepancies  requiring  cor- 
rection. In  the  second  place,  records  of  dispensaries  often  made  possible 
a  precise  medical  defination  of  the  nature  of  the  ailment.  The  difference 
was  one  of  precision  rather  than  correctness  of  statement,  however,  be- 
cause the  reports  of  the  family  were  with  but  few  exceptions  confirmed 
by  the  examination  of  the  medical  record. 

The  tabulation  of  the  data  collected  was  made  by  the  statistical 
staff  employed  by  the  Commission.  All  the  information  appearing 
upon  the  schedule  was  taken  off  for  the  first  rough  tabulation.  Because 
of  the  great  mass  of  data  secured  and  the  many  possible  interrelations 
of  different  facts  the  Commission  had  neither  the  staff,  time^  nor  funds, 
to  work  out  all  the  many  possible  final  tables  bearing  upon  the  problem 
of  sickness  in  its  relation  to  other  factors.  Only  the  more  important 
points  such  as  age,  sex,  nationality,  economic  status,  duration  of  sick- 
ness and  sickness  costs,  nature  and  extent  of  protection  against  sickness, 
have  been  analyzed  in  detail.  There  remains  in  the  possession  of  the 
Commission  a  mass  of  data  unexploited  but  valuable  from  the  stand- 
point of  public  health,  economics  and  sociology.  Of  the  3,980  families 
studied  888  had  dispensary  records.  The  tables  based  upon  the  data 
secured  relative  to  dispensary  service  are  not  presented  in  this  study 
but  form  part  of  the  special  report  on  dispensaries.^ 

{3)   General  Classification  of  Families. 

The  families  in  the  different  divisions  of  the  Family  Study  are 
classified  as  follows : 

Depend ent  and  independent  families. — The  status  of  the  families 
m  the  charity  group  is  at  once  determined  by  their  receipt  of  charity. 
Their  status  is  dependency;  the  family  is  designated  as  dependent. 
With  only  few  exceptions  the  families  in  the  blocks  studied  and  those 
from  the  lists  of  the  Visiting  Nurse  Association  are  independent  and 
fall  into  three  distinct  groups  according  to  industrial  status. 

Wage-earning  families. — ^A  wage-earning  family  is  one  in  which 
the  normal  or  the  chief  breadwinner  is  working  for  an  employer  for  a 
stipulated  wage  paid  most  frequently  by  the  week,  but  occasionally  by 
the  day  or  the  month. 

Families  ''on  own  account.'' — A  family  *''on  own  account''  is  one  in 
which  the  normal  or  chief  breadwinner  is  "self-employed,"  i.  e.,  gainfully 
occupied  in  an  enterprise  in  which  he  has  assumed  the  risk  of  the  business. 

''Retired''  families. — A  "retired''  family  is  one  no  member  of  which 
is  gainfully  occupied  either  as  wage-earner  or  self-employed. 

2  See   Part   II,    Special   Report   III. 


185 

(4)   Determination  of  Economic  Status. 

The  total  incomes  of  the  families,  without  respect  to  size  and  com- 
position, do  not  provide  a  satisfactory  basis  for  determining  their  eco- 
nomic condition.  Nor  do  the  wages  of  the  normal  breadwinners  supply 
a  more  satisfactory  criterion.  Students  of  the  relation  between  wages 
and  standards  of  living  have  deserved  reproach  by  not  always  taking 
into  account  all  the  sources  of  family  income  or  of  the  necessary  vari- 
ations in  budgets  with  reference  to  family  composition  by  number, 
sex,  age  and  employment  of  its  members.  From  the  standpoint  of  family 
income,  the  number  of  wage-earners  in  the  family  and  their  contribution, 
as  well  as  income  from  boarders  and  roomers,  rent  and  all  other  sources 
must  be  included.  In  estimating  family  budgets  significant  variations 
occur  not  only  by  size  of  family,  but  also  with  age  and  sex  of  its  memberc. 
For  these  reasons,  it  was  considered  desirable  for  use  in  certain  con- 
nections to  classify  wage-earning  families  according  to  the  relation  be- 
tween the  total  family  income  from  all  sources  and  the  requirements  of 
budgets  of  different  levels  of  expenditure. 

For  the  purpose  of  correlating  sickness,  the  cost  of  sickness,  in- 
surance and  other  details  with  economic  "status"  or  position,  our  wage- 
earning  families  have  been  divided  into  three  classes  lettered  "A,"  "B," 
and  "C."  For  some  purposes  class  "A"  has  been  subdivided  so  as  to 
give  a  fourth  class  lettered  "W."  In  all  cases  basic  figures  have  been 
taken  for  a  family  consisting  of  man,  wife,  and  three  children  under  15 
and  these  basic  figures  have  then  been  reduced  for  smaller  and  increased 
for  larger  families  in  the  way  presently  described. 

What  was  desired  was  to  divide  the  families  into  three  groups — 
those  whose  incomes  could  not  meet  the  test  of  a  poverty  budget;  those 
whose  incomes  would  meet  this  test  but  not  the  test  of  a  "decency  budget ;" 
and  those  whose  incomes  would  meet  the  test  of  a  "decency  budget." 
Such  a  classification  we  have,  however,  been  unable  to  make.  While  a 
fairly  satisfactory  basic  poverty  budget  figure  ($850)  was  available  as 
a  guide,  the  cost  of  decent  living  had  not  been  satisfactory  studied  and  we 
did  not  have  the  time  and  funds  required'  to  make  the  needed  investi- 
gation. What  has  been  done  is  to  use  a  poverty  budget  to  ascertain  how 
many  of  the  wage-earning  families  had  deficient  or  poverty  incomes. 
These  families  have  been  lettered  "C."  Their  incomes  are  "deficient" 
as  tested  by  a  conservative  budget.  With  Class  C  families  separated  out, 
a  second  basic  figure,  viz:  $1,200,  has  been  used  to  divide  the  remain- 
ing families  into  two  classes.  These  are  lettered  "B"  and  "A."  To  be  in 
Class  B  means  to  have  a  meager  income,  an  income  not  to  exceed  approxi- 
mately 41  per  cent  more  than  the  poverty  budget  would  be.  To  be  in 
Class  A  means  that  the  income  is  less  meager  or  that  the  family  is  better 
off  than  the  family  in  Class  B.  Some  have  moderate  incomes,  others  do 
not.  Certainly  many  of  them  have  incomes  insufficient  to  cover  the  cost 
of  decent  living  for  that  would  be  $100  to  $200  more  than  the  $1,200 
basic  figure  employed  in  this  classification.  For  most  purposes  this 
three-fold  grouping  has  been  used.     At  certain  points,  however,  it  has 


186 

been  desirable  to  establish  a  fourth  class,  letter  "VV."  This  has  been  done 
by  using  $1,500  as  the  basic  figure. 

It  is  now  apparent  that  in  determining  economic  classes  we  have 
selected  a  povery  budget,  and  then  upon  this  have  superimposed  an  inter- 
mediate and  an  upper  budget  level  arbitrarily  taken.  The  manner  of 
finding  a  poverty  or  subsistence  budget  and  of  adapting  it  to  the  re- 
quirements of  this  study  will  be  briefly  described. 

In  order  to  secure  such  a  basic  standard  it  was  considered  desirable 
to  select  a  charity  budget  actually  in  use  in  Chicago.  Social  agencies  in 
the  city  engaged  in  the  work  of  family  rehabilitation  have  for  several 
years  been  working  out  what  may  be  called  poverty  budgets  in  order  to 
determine  the  smallest  amount  of  pecuniary  relief  necessary  to  provide 
for  the  bare  necessities  of  life.  In  order  to  secure  such  a  standard  the 
budgets  in  use  in  the  year  1917-1918  by  the  United  Charities,  the  Jewish 
Aid  Society,  and  by  the  Funds  to  Parents  Department  of  the  Juvenile 
Court  were  consulted.  All  these  budgets,  although  different  in  detail, 
were  found  to  be  variations  of  a  basic  budget  prepared  by  Miss  Florence 
Nesbitt,  one  of  the  leading  authorities  on  budget  making  for  needy 
families  in  the  United  States.  After  consideration  of  all  these  budgets, 
that  prepared  for  the  Funds  to  Parents  Department  of  the  Juvenile 
Court  was  selected  for  use  with  certain  modifications.  Two  points  had 
considerable  weight  in  making  this  choice.  It  was  the  most  conservative 
budget  estimate  of  those  at  hand.  Moreover,  it  was  the  only  budget 
actually  in  use  with  all  families  under  the  care  of  any  of  the  relief 
agencies  of  the  city. 

The  standard  budget  family,  as  understood  in  studies  of  the  standard 
of  living  and  of  family  budgets,  consists  of  the  wage-earner,  his  wife, 
one  child  between  ten  and  fourteen  years,  and  two  children  under  ten 
years  of  age.  The  following  table  shows  for  various  items  necessary  for 
subsistence,  the  figures  of  the  Funds  to  Parents  Budget  and  those  adopted 
for  our  poverty  or  subsistence  budget. 


Funds 

to  parents 

budget. 


Subsistence 
budget  used  in 
family  study. 


Food 

Clothing 

Rent 

Heat  and  light 

Household  expenses  and  incidentals. 

Health 

Carfare 


Total  subsistence  budget . 


$475  80 

132  00 

120  00 

66  00 

42  00 

15  00 


$850  80 


$475  80 

131  00 

120  00 

66  00 

42  00 


15  00 


$849  80 


The  estimates  for  each  item  are  undoubtedly  conservative  for  the 
year  of  the  study  because  of  the  rise  in  the  cost  of  living  after  the  time 
of  their  determination  according  to  prices  in  October,  1917.  However, 
October  would  be  quite  close  to  the  mid-point  of  the  year  of  the  study 
for  our  charity  families  while  the  mid-point  of  the  year  of  the  investi- 
gation for  the  block  and  Visiting  Nurse  Association  families  would  be 


187 

closer  to  January,  1918.  The  amounts  assigned  to  the  various  items 
taken  together  gave  the  irreducible  minimum  budget  necessary  to  main- 
tain physical  efficiency. 

The  chief  difference  between  the  Funds  to  Parents  Budget  and  our 
Family  Study  Budget  figures  is  in  the  elimination  of  the  item  for  health 
(since  dependence  on  free  medical  service  was  assumed)  and  the  insertion 
of  a  specified  amount  for  carfare.  The  discrepancy  of  one  dollar  in  the 
sums  assigned  to  the  item  for  clothing  is  due  to  a  minor  modification 
made  necessary  in  simplifying  the  age-grouping  as  described  under  the 
item  ^"clothing." 

A  short  statement  may  be  made  of  the  method  of  determining  the 
different  items  included  among  the  necessaries  of  existence. 

Food. — For  food  the  allowance  as  fixed  by  the  Funds  to  Parents 
Budget  was  based  on  current  prices  of  foods  necessary  to  meet  scientifi- 
cally determined  standards  of  food  values  in  relation  to  adequate 
nutrition.  The  items  vary  with  the  age  and  sex  of  members  of  the 
family. 

Yearly- 
amount. 

Adult  male,  15  years  of  age  and  over $130.00 

Adult  female,  15  years  of  age  and  over 101.40 

Older  child,  10  to  14  years,  inclusive 88.40 

Younger  children  (under  10  years  of  age) 78.00 

Clothing. — The  difference  of  one  dollar  in  the  subsistence  budget 
used  in  the  Family  Study  and  that  of  the  Funds  to  Parents  Department 
is  explained  by  the  data  in  the  following  table : 


Family  composition. 


Yearly  amount  for  clothing. 


Funds 

to  parents 

budget. 


Subsistence 

budget  (used  in 

family  study.) 


Adult  male,  15  years  of  age  and  over $45  146 

Adult  female,  15  years  of  age  and  over 30  30 

Older  children  10  to  14  years  inclusive 24  24 

Younger  children  (under  10  years  of  age) 16 

Younger  children  5-9  years  inclusive 

Younger  children  1-4  years  inclusive 


In  combining,  for  the  Family  Study,  the  two  age-groups  5-9  years 
and  1-4  years,  the  sum  of  $16  for  clothing  was  fixed  upon.  With  one 
younger  child  of  9  years  and  another  of  4  years  the  sum  for  the  two  would 
be  $33  under  the  subsistence  budget  of  the  Funds  to  Parents  Department, 
and  $32  or  one  dollar  less  under  that  used  in  the  Family  Study. 

Rent. — In  the  Funds  to  Parents  Budget  no  fixed  amount  had  been 
assigned  to  rent.  The  usual  phrase  is  rent  "as  has  been  paid"  or  "as 
necessary  for  good  housing."  Through  the  cooperation  of  Miss  Edith 
Abbott  of  the  School  of  Civics  and  Philanthropy  a  tabulation  was  avail- 
able for  use  in  the  Family  Study  of  the  rents  actually  paid  by  the  families 
receiving  pensions  under  the  Funds  to  Parents  Law.  On  the  basis  of 
the  data  from  this  study  a  scale  of  rents  corresponding  to  size  of  family 
was  worked  out.  For  the  family  of  five  the  average  monthly  rent  was 
found  to  be  $10  or  $120  for  the  year. 


188 

Heat  and  light. — The  item  of  %Q>^  per  year  for  two  stoves  as  given 
by  the  Funds  to  Parents  Budget  was  accepted  without  modification,  and 
was  applied  to  all  families  regardless  of  size. 

Household  expenses  and  incidentals. — This  item,  of  necessity,  varies 
with  the  size  of  family.  Here  again  the  amount  as  fixed  by  size  of 
family  in  the  Funds  to  Parents  Budget  was  adopted. 

Carfare. — In  the  charity  budgets  no  fixed  amount  was  entered  for 
carfare.  The  allowance  made  is  according  to  what  is  regarded  "as  neces- 
sary.^^ Since  the  family  study  was  dealing  with  groups  rather  than  with 
individuals  it  was  necessary  to  make  an  estimate  of  the  average  annual 
amount  required  for  carfare  in  a  wage-earning  family.  The  irreducible 
minimum  of  expenditure  for  carfare  was  finally  considered  to  be  that 
necessary  for  the  wage-earner  in  going  to  and  returning  from  work. 
Assuming  that  there  are  300  working  days  in  the  year  and  that  only 
half  of  the  wage-earners  require  transportation  to  and  from  work,  $15 
a  year  was  added  for  each  wage-earner  in  a  family. 

The  income  figure  ($850)  necessary  to  meet  a  subsistence  or  poverty 
budget  is,  of  course,  applicable  only  to  the  standard  budget  family  of 
father,  mother,  and  three  children  under  fifteen  years  of  age.  Using  the 
standard  budget  family  figure  ($850)  as  a  basis,  other  income  figures 
were  worked  out  by  determining  need  according  to  size  and  composition 
of  family  by  sex  and  age.  From  the  standpoint  of  budget  needs  only 
four  of  the  many  possible  groupings  by  age  and  sex  were  recognized: 
(a)  adult  males  fifteen  years  of  age  and  over;  (b)  adult  females  fifteen 
years  of  age  and  over;  (c)  older  children  between  ten  and  fourteen  years 
inclusive;  (d)  children  under  ten  years.  If  we  assume  that  every  family 
has  at  least  one  adult,  15  years  of  age  and  over,  the  following  represent 
the  theoretical  permutations  in  composition  of  the  family  according  to 
its  size ;  with  1  member  2  combinations ;  with  2  members  7  combinations ; 
with  3  members  16  combinations;  with  4  members  30  combinations; 
with  5  members  47  combinations ;  with  6  members  70  combinations ;  with 
7  members  96  combinations;  with  8  members  124  combinations;  with 
9  members  150  combinations;  or  a  total  of  542  combinations,  or  types 
of  budget  families.  For  each  of  these  542  budget  families  a  figure  cor- 
responding to  $850  was  worked  out. 

The  method  of  determining  a  "minimum'^  standard  of  living  for  the 
bare  necessities  of  life  has  been  sufficiently  described.  In  the  absence 
of  any  acceptable  study  of  the  cost  of  "decent  living,^^  an  arbitrary  flat 
rate  increase  over  the  figures  of  the  subsistence  budget  was  taken.  For 
the  standard  budget  family  where  the,  subsistence  budget  figure  was 
$850,  the  higher  figure  was  fixed  at  $1,200  which  represented  an  increase 
of  41.2  per  cent.  Twelve  hundred  dollars  is  a  good  round  sum,  about 
two-fifths  higher  than  the  actual  standards  of  Chicago's  charitable 
agencies,  and  therefore  presumably  making  possible  a  margin  of  ex- 
penditure for  some  decencies  over  and  above  the  absolute  necessities  of 
life.  It  is  to  be  stated  emphatically,  however,  that  $1,200  was  selected 
arbitrarily  as  a  convenient  amount,  and  not  with  the  idea  that  it  would 
cover  the  cost  of  what  is  known  as  "decent  living."     No  doubt  a  "decency 


189 

budget/'  as  the  term  is  loosely  used,  would  have  required  an  addition  of 
$100  or  $200  to  the  figure  selected. 

Using  this  basic  sum  ($1,200),  figures  were  accordingly  worked  out 
for  the  542  types  of  families  ranging  from  one  to  nine  in  membership  by 
the  addition  of  a  flat  increase  of  41.2  per  cent  to  the  corresponding 
subsistence  budget  figures.  This  series  of  budget  figures  taken  col- 
lectively will  hereafter  be  known  as  the  "intermediate"  budget. 

By  working  out  two  budget  levels  in  the  way  indicated,  it  became 
possible  to  group  the  families  into  three  classes  known  as  "A,''  "B,"  and 

Class  C.  Families  with  deficient  incomes. — Where  the  total  family 
income  was  insufficient  to  provide  for  the  subsistence  budget  the  family 
is  classified  under  "Class  C^'  or  "families  with  deficient  income." 

Class  B.  Families  with  meager  incomes. — Where  the  total  family 
income  was  sufficient  to  provide  for  the  subsistence  budget,  but  was  in- 
sufficient to  provide  for  the  intermediate  budget,  the  family  is  classified 
under  "Class  B"  or  "families  with  meager  income." 

Class  A.  Families  with  higher  incomes. — Where  the  total  family 
income  was  sufficient  to  provide  for  the  intermediate  budget,  the  family 
is  classified  under  "Class  A"  or  "families  with  higher  incomes,"  or 
families  "better  off"  than  those  in  Class  B.  In  certain  sections  of  the 
study.  Class  A  is  further  subdivided  into  two  classes.  The  separating 
line  between  these  classes  is  fixed  at  a  still  higher  budget  level  which  is 
designated  as  the  "upper"  budget.  The  "upper^^  budget  is  quite  arbi- 
trarily fixed  at  25  per  cent  higher  than  the  "intermediate"  budget.  For 
the  standard  budget  family  of  father,  mother,  an  older  child  and  two 
younger  children,  where  the  "subsistence"  budget  is  $850  and  the  "inter- 
mediate" budget  $1,200;  the  "upper"  budget  is,  accordingly,  $1,500. 
Families  in  Class  A  whose  incomes  were  below  the  requirements  of  the 
"upper'  budget  are  classified  in  sub-class  "A,"  or  families  ^iDetter  off;" 
families  in  Class  A  whose  incomes  were  above  the  level  of  the  "upper" 
budget  are  classified  in  sub-class  "W"  or  "families  still  better  off"  or 
"best  off,"  so  that  they  may  be  spoken  of  as  "well  off."  The  term  "well 
off"  is  used  in  a  strictly  relative  sense  and  signifies  "well  off"  as  incomes 
go  in  the  wage-earning  group.  In  general,  however,  families  'better  off" 
and  those  "well  off"  are  grouped  together  in  Class  A. 

An  objection  may  be  made  that  the  economic  status  assigned  to 
many  families  is  likely  to  be  incorrect  because  reports  of  incomes  in 
certain  cases  are  too  high  or  too  low.  The  claim  is  not  made  that  the 
determination  of  economic  status  is  correct  for  each  individual  family. 
It  is  probably  erroneous  in  a  few  cases  of  conscious  or  unconscious  over- 
statement or  understatement  of  wages  and  of  occasional  omission,  in- 
tentional or  unintentional,  of  certain  sources  of  income.  While,  there- 
fore, not  absolutely  accurate  for  all  individual  families,  the  assignment 
of  economic  status  does  adequately  characterize  the  relationship  of  income 
to  need  of  broad  groups  of  wage-earning  families  which  is  sufficient  for 
most  of  the  purposes  of  this  study. 

The  following  table  shows  bv  different  budget  levels  both  the  amount 
assigned  as  determined  for  the  standard  budget  family  of  five  members 


190 


and  the  range  of  budget  figures  b)^  size  of  family  for  each  selected  type 
of  its  composition. 

BUDGET  FIGURES  AS  DETERMINED  FOR  THE  STANDARD  BUDGET 
FAMILY  AND  BY  LOWEST  AND  HIGHEST  FIGURES  ACCORDING  TO 
COMPOSITION  OF  FAMILIES  OF  1  TO  9  MEMBERS. 


1 

o 

Subsistence  budget  figures. 

Intermediate  budget  figures. 

Upper  budget  figures. 

Standard 
budget 
family. 

Lowest. 

Highest. 

Standard 
budget 
family. 

Lowest. 

Highest. 

Standard 
budget 
family. 

Lowest. 

Highest . 

1 

2 
3 
4 
5 
6 
7 
8 
9 

J849.80 

$    296.40 
408. 40 
520.  40 
638.  40 
750.  40 
856.  40 
963.40 
1,092.80 
1,211.20 

$    340.00 

533.  00 

726.00 

925.00 

1,118.00 

1,305.00 

1,498.00 

1,685.00 

1,856.00 

$1,200 

$    418.60 

576. 70 

734.90 

901.  50 

1,059.60 

1,209.30 

1,367.50 

1, 543. 10 

1,710.30 

$    480.10 

752. 70 

1,025.20 

1,306.20 

1,578.70  51,500 

1, 842.  80 
2, 115. 30 
2,379.40 
2,635.00 

$    523.30 
720. 90 
918.  60 
1, 126.  90 
1,324.50 
1,511.60 
1,709.40 
1,928.90 
2, 137.  90 

$    600.10 
940, 90 
1,281.50 
1,636.80 
1,973.40 
2,303.50 
2,644.10 
2,974.30 
3,293.80 

The  distinction  between  normal  and  actual  economic  status. — In 
relating  economic  status  to  the  problem  of  sickness,  it  is  important  to 
make  the  distinction  between  normal  and  actual  economic  status.  Nor- 
mal economic  status  is  determined  by  adding  to  the  total  actual  family 
income  for  the  year  of  the  study  the  amount  of  wages  lost  by  reason  of 
sickness  by  wage-earners  in  the  family.  Actual  economic  status  is  de- 
termined by  deducting  from  the  total  actual  family  income  the  costs  of 
medical  treatment. 

Year  of  the  study. — The  year  of  the  study  for  each  family  visited 
was  the  twelve  months  ending  with  the  date  of  the  visit.  For  the  charity 
families  the  year  ended  approximately  with  May  1,  1918,  for  the  block 
and  visiting  nurse,  cases  with  July  15,  1918.  The  unusual  character  of 
the  year  from  an  industrial  standpoint  must  always  be  considered  in  the 
analysis  and  interpretation  of  the  data  presented  in  the  Family  Study. 
During  the  year  the  cost  of  living  steadily  rose,  but  this  was  more  than 
offset  by  the  favorable  industrial  conditions.  Wages  tended  to  rise, 
though  not  as  universally  as  prices.  However,  in. general,  actual  incomes 
in  wage-earning  families  appear  to  have  been  larger  than  in  former 
years,  in  part  because  of  wage  increases,  but  in  greater  part  because  of 
regularity  of  work  and  persistent  demand  for  labor.  Unemployment 
during  the  year  reached  a  low  level.  The  data  drawn  from  the  family 
studies  must  be  used  holding  in  mind  that  the  year  was  above  normal  for 
wage-earning  families. 

(5)   Population  and  Income  Statistics. 

Before  taking  up  the  separate  studies  in  detail,  it  is  desirable  to 
present  the  population  and  income  data  for  the  families  in  the  block, 
nursing  service  and  charity  studies,  relative  to  their  nationality,  age, 
sex,  family  composition,  economic  status,  and  income  from  wasres  and 
other  sources.  Table  1  persents  family  composition  by  nationality  and 
by  size.  The  total  number  of  families  in  our  three  studies  is  3,980. 
The  total  members  of  these  families  is  17,475.     The  nationality  distri- 


191 


TABLE    1 — ^FAMILY    COMPOSITION    BY    NATIONALITY    AND    BY    SIZE. 


o 

u 

^a 

Total  number 
members  in 
families. 

Size  of  families  by  number  of  members. 

Nativity  or  race  of  head  of 
family. 

O 

6 
Eh 

<i3 
£ 

S 
^ 

K 
02 

03 

i 

i 

•0 

es 

>  ^ 

Eh 

Block  studv 

3,048 

12,450 

106 

559 

718 

609 

400 

293 

178 

97 

55 

15 

12 

6 

United  States,  white 

644 
274 
243 
240 
129 
204 
218 
117 
522 
232 
225 

304 

129 
30 

6 
41 
14 

9 
22 

2,385 
854 
942 
917 
601 

1,017 

1  116 
488 

2,434 
798 
898 

1,550 

17 
28 

6 
15 

9 
.... 

3 

3 

19 

5 

2 

142 
105 
38 
51 
14 
29 
25 
11 
55 
54 
35 

15 

194 
61 
67 
52 
19 
31 
24 
32 

118 
58 
62 

61 

125 
34 
57 
52 
26 
39 
37 
27 

105 
56 
51 

58 

78 
18 
43 
26 
16 
23 
40 
22 
76 
18 
40 

55 

43 
15 
•  20 
19 
23 
28 
39 
10 
69 
13 
14 

47 

21 
5 
5 

11 

10 

28 

30 

7 

45 

7 

9 

26 

10 
1 
4 

11 
4 

13 

10 
5 

29 
7 
3 

16 

13 
4 
2 
3 
3 
8 
6 

1 

United  States,  colored 

Bohemian 

2 

German 

Irish  

2 
1 
3 

3 
2 

2 

Italian 

1 

Jewish 

1 

Lithuanian 

Polish 

16 

4 

2 

Scandinavian 

Other 

11 

4 
6 

2 

7 

Nursing  service  study 

United  States,  white 

United  States,  colored 

Bohemian 

638 

138 
29 

229 
68 
44 

126 

1 

7 

31 
10 
2 
4 
3 
2 
3 

22 
6 
2 
8 
3 
2 
4 

22 
5 

'"5 
2 
3 
3 

21 
5 
1 

6 
1 
1 
6 

11 
1 

6 

3 
.... 

5 

1 
1 

4 

1 

German 



5 

1 

2 
3 

3 

1 

2 

1 

Irish 

Italian 

1 

1 

Jewish 

2 

2 

1 

Lithuanian 

Polish 

13 
14 

26 

628 

79 

62 

137 

3,475 

4 
5 
2 

103 

3 
3 
9 

106 

'"2 
4 

113 

2 
1 
4 

82 

17 
5 
2 
8 
4 

14 
6 
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1 

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3 



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— 

Scandinavian 

2 

1 
1 

43 

2 
4 

63 

Other 

1 
64 

36 

1 

10 

Charity  studv 

5 

1 

United  States,  white 

United  States,  colored 

Bohemian 

115 
23 
15 

69 
46 
79 
39 
8 
126 
27 
81 

590 
128 

92 
355 
211 
507 
221 

41 
776 
113 
441 

.... 

1 

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5 

1 
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10 

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3 

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24 
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1 
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3 
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1 
2 
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German 

1 

1 
4 

2 

Irish 

Italian 

Jewish 



■"'2 

4 

7 

4 
3 
7 
4 
9 

Lithuanian     

Polish 

3 

Scandinavian 

Other 

7 

192 

Dution  by  race  and  nativity  of  father  is  United  States  White  with  888 
lamilies  and  3,613  members;  United  States  Colored  with  327  families 
and  1,120  members;  Poles  with  661  families  and  3,289  members;  Bo- 
nemians  with  264  families  and  1,063  members;  Germans  with  350  fami- 
nes and  1,501  members;  Italians  with  292  families  and  1,568  memoers; 
Jews  with  279  families  and  1,463  members;  Scandinavians  with  273 
lamilies  and  973  members;  Irish  with  189  families  and  880  members; 
and  Lithuanians  with  125  families  and  529  members.  Where  the  fattier 
IS  foreign-bom  of  other  national  group  the  families  number  332  with 
1,476  members.  Nationality  has  been  assigned  to  the  foreign-born  by 
mother-tongue  rather  than  by  country  of  birth.  However,  except  with 
the  Jewish,  the  nationality  will  correspond  closely  to  the  probable  re- 
distribution in  Europe. 

The  average  size  of  the  family,  with  all  divisions  of  the  study  taken 
collectively,  is  4.4.  This  is  just  under  the  average  (4.6)  returned  for 
Chicago  by  the  United  States  Census  in  1910.  The  average  size  of  the 
family,  however,  is  not  uniform  for  the  groups  in  our  different  studies. 
For  the  families  in  the  blocks  the  average  size  is  only  4.1,  for  the  nursing 
service  families  5.1,  for  the  charity  families,  5.5.  Nor  is  the  size  of  the 
family  uniform  by  nationality.  Arranging  nationalities  in  descending 
order  by  average  number  of  members  we  have:  Italian,  5.4;  Jew,  5.2; 
Pole,  5.0;  Irish,  4.7;  "Other  Nationalities,"  4.4;  German,  4.3;  Lithuan- 
ian, 4.2;  United  States  White,  4.1;  Bohemian,  4.0;  Scandinavian,  3.6; 
CJnited  States  Colored,  3.4. 

Table  2  exhibits  the  distribution  of  the  17,475  members  of  the  3,980 
families  by  sex  and  age.  With  the  sex  of  422  not  reported,  the  total 
number  of  males  is  8,342 ;  of  females,  8,711,  or  a  ratio  of  48.9  males  to 
51.1  females.  The  1910  census  showed  a  larger  number  of  males  than 
of  females.  The  smaller  ratio  of  males  in  our  families  is  to  be  accounted 
for  in  part  by  the  larger  number  of  females  in  the  charity  group  and  by 
the  large  number  of  young  men  who  were  in  the  Army  and  Navy  in  1917- 
18  and  therefore  not  included  in  the  study.  The  age  distribution  in  the 
charity  cases  shows  a  larger  proportion  of  young  children  and  old  per- 
sons than  in  the  block  study.  Distribution  by  age  in  the  blocks  corres- 
ponds, in  general,  to  that  shown  by  the  United  States  Census,  as  indi- 
cated by  the  following  table: 


Age  groups.  . 


Age  group  per  cent  of  total 
population. 


Chicago— 1910 
census. 


Block  study. 


Under  5  years . . . 

Under  1  year 

5-9  years 

10-14  years 

15-19  years 

20-24  years 

25-34  years 

35-44  years 

45-64  years 

65  years  and  over 
Age  unknown... 


14.5 

3.3 

13.0 

9.8 

8.0 

7.2 

17.3 

12.9 

13.0 

(2.4 

1.9 


193 


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In  two  age-groups  the  proportion  of  persons  in  the  blocks  differ 
greatly  from  the  Chicago  Census  percentage.  The  relative  number  of 
children  under  10  years  of  age  is  markedly  higher  in  our  block  study. 
On  the  other  hand,  the  proportion  of  persons  in  the  age-group  20  to  24 
years  is  much  lower.  The  figures  in  Table  2  also  present  a  relatively 
low  number  of  males  in  the  age-group  of  20-24  years  which  roughly 
corresponds  to  the  age  period  of  the  draft. 

Table  3  shows  size  of  family  classified  by  economic  status  in  the 
blocks  and  nursing  service  cases.  The  essentials  are  presented  in  the 
following : 


Normal  economic  status. 


Families  in 

block  and 

nursing 

service 

studies. 


Families 

in  block 

study. 


Families 
in 

nursing 
service 
study. 


Class  A,  the  better  off  families 

Class  B  (families  with  meager  incomes) 

Class  C  (families  with  deficient  incomes) 

Class  D  (families  with  incomes  not  reported  in  full) 

Class  O  (families  "  on  own  account") 

Class  R  (families  "retired") 


3.66 

3.61 

4.97 

4.89 

5.90 

5.43 

4.26 

4.24 

4.27 

4.20 

2.34 

2.32 

4.30 
5.58 
6.69 
5.50 
5.0i 
2.68 


While  the  average  size  of  the  nursing  service  families  is  larger  than 
that  of  block  families,  the  variations  by  economic  status  are  remarkably 
similar  in  both  studies.  The  average  size  of  the  "retired"  families  is 
small.  Table  3  shows  that  62  per  cent  of  them  consist  of  one  or  two 
members.  The  average  size  of  families  in  Class  0,  or  "on  own  account/' 
is  4.2  as  compared  with  4.1  for  all  block  families,  but  is  considerably 
higher  than  the  average  size  (3.6)  of  families  in  Class  A  with  the  higher 
incomes  and  much  lower  than  the  average  size  (4.9)  of  families  m  Class 
B  with  meager  incomes,  or  the  average  size  (5.4)  of  families  in  Class  C 
with  deficient  incomes. 

Table  3  presents  in  great  detail  the  number  and  proportions  of 
persons  in  families  of  different  sizes  according  to  economic  status.  These 
figures  provide  more  opportunity  for  analysis  than  space  permits.  It 
is  sufficient  to  call  attention  to  the  largest  proportion  of  families  accord- 
ing to  number  of  members  with  reference  to  economic  status.  Com- 
bining the  figures  for  the  block  and  nursing  service  studies,  the  largest 
proportion  of  families  in  Class  A  (31.4  per  cent)  consist  of  three  mem- 
bers; in  Class  B  (23.3  per  cent)  consist  of  five  members;  in  Class  C 
(18.0  per  cent)  consist  of  seven  members;  in  Class  D  (29.5  per  cent) 
consist  of  three  members;  in  Class  0  (17.5  per  cent)  consist  of  four  mem- 
bers; in  Class  E,  "retired"  (31.7  per  cent)  consist  of  one  member;  in  the 
charity  families  (18.0  per  cent)  consist  of  six  members. 


195 


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The  following  table  shows  by  economic  status  the  number  of  families 
with  husband  and  wife  present,  and  the  number  with  husband  or  wife 
or  both  absent. 


Total 

number  of 

families. 

Number  of  families  with 

Per  cent  of 

Economic  status. 

0 

Husband 
and  wife. 

Widower. 

Widow. 

Neither 

husband 

or 

wife. 

families 

with 
husband 
and  wife. 

Block  study 

3,048 

2,577 

63 

360 

48 

84.5 

Class  A . 

1,687 
631 
280 
110 
267 
73 

304 

1,458 
563 
226 

84 
217 

29 

285 

38 
5 
1 
4 

10 
5 

164 
60 
52 
21 
33 
30 

18. 

27 
3 
1 

1 
7 
9 

1 

86.4 

Class B 

89.2 

Class  C 

80.7 

Class  D 

76.4 

Class  0  

81.3 

Class  R 

39.7 

Nursing  service  study 

93.8 

Class  A 

132 
91 
48 

2 
25 

6 

628 

125 
89 
43 

6 
2 
5 
2 
1 
2 

104 

1 

94.7 

Class  B  

97.8 

Class  C 

89.6 

Class  D 

0.0 

Class  0  

24 
4 

518 

96.0 

Class  R  

66.7 

Charity  study 

4 

2 

82.5 

The  proportion  of  families  with  both  husband  and  wife  is  largest  in 
the  nursing  service  study,  with  93.8  per  cent  of  the  total  number;  next 
largest  in  the  block  study,  with  84.5  per  cent  of  the  total  number ;  small- 
est in  the  charity  stud}-,  with  82.5  per  cent  of  the  total  number.  The 
small  difference  between  the  percentages  of  disrupted  families  in  the 
charity  and  block  groups  is  to  be  explained  largely  by  the  transfer  of 
widows  with  children  to  the  care  of  the  Funds  to  Parents  Department 
of  the  Juvenile  Court  and  to  the  institutional  care  of  the  widowed  aged. 
It  seems  quite  evident  that  the  304  cases  in  the  nursing  service  study 
are  not  representative  of  Chicago's  wage-earning  population  in  this 
respect  or  in  regard  to  the  size  of  the  family  or  to  the  nationality  of  the 
father.  The  variation  in  family  composition  by  economic  status  is 
interesting.  In  the  block  families  the  largest  proportion  of  families 
not  disrupted  by  death  or  desertion  of  husband  or  wife  is  in  Class  B 
with  89.2  per  cent,  followed  hy  Class  A  with  86.4  per  cent.  Class  0  with 
81.3  per  cent.  Class  C  with  80.7  per  cent,  Class  D  with  76.4  per  cent,  and 
Class  R  with  39.7  per  cent. 

The  data  for  family  incomes  and  deficits  were  worked  out  in  detail. 
Table  4  presents  an  analysis  of  incomes  by  the  industrial  status  of  fami- 
lies classified  as  wage-earning,  on  own  account,  and  retired.  The  various 
sources  of  the  family  income  are  separately  indicated  and  income  from 
wages  and  from  business  on  own  account  are  presented  by  the  amount 
contributed  by  individual  members  of  the  family  grouped  as  husbands, 
wives,  unmarried  males  16  years  of  age  and  over,  unmarried  females  16 


199 

years  of  age  and  over,  and  children  under  16  years  of  age.     A  summary 
table  giving  totals  and  averages  for  family  incomes  and  deficits  follows. 


Type  of  family. 


Number 

Total 

Total 

of 

incomes 

Number 

Number 

number  of 

families 

of 

Average 

of 

of 

Amount 

families 

reporting 

families 

family 

families 

families 

of 

investi- 

incomes 

report- 

income. 

without 

with 

deficits. 

gated. 

and 
balances. 

ing  com- 
pletely. 

deficits. 

deficits. 

Average 
deficit  for 

family 
with 

deficit. 


Block  study 

Wage  earning. . . 

Self-employed... 

Other 

Nursing   service 
study 

Wage  earning. . . 

Self-employed... 

Other 

Charity  study 

Wage  earning. . . 

Self-employed... 

Other 


3,048 

2,806 

$3,713,746 

$1,323.50 

2,470 

336 

$66,086 

2,708 

2,559 

3,331,022 

1,301.68 

2,269 

290 

44,692 

267 

191 

349,351 

1,829.06 

170 

21 

10, 123 

73 

56 

33,373 

595.96 

31 

25 

11,271 

304 

285 

357,423 

1,254.12 

179 

106 

13,849 

273 

261 

331,011 

1,268.24 

161 

100 

12,651 

25 

20 

24,768 

1,238.40 

17 

3 

784 

6 

4 

1,644 

411.00 

1 

3 

414 

628 

528 

307, 139 

581.  70 

58 

470 

118,354 

563 

474 

293,701 

619. 62 

56 

418 

101,202 

25 

21 

11,797 

561. 76 

2 

19 

4,096 

40 

33 

1,641 

49.  73 

33 

13,056 

$196. 68 
154.11 
482. 05 
450.84 

130. 65 
126.51 
261.33 
138.00 
251.  82 
242. 11 
215.  58 
395.64 


Both  the  detailed  and  the  summary  tables  will  have  an  interest  for 
special  students  of  the  problem  of  family  income  quite  beyond  the  field 
of  the  present  study.  While  at  this  point  no  comment  will  be  made  upon 
the  similarities  and  the  contrasts  evident  in  the  tables,  the  data  presented 
here  provide  the  background  for  an  understanding  of  the  general  eco- 
nomic situation  of  the  different  groups  of  families  studied. 

With  this  introduction  to  the  purpose,  scope  and  methods  of  investi- 
gation and  to  the  groups  of  families  studied,  we  take  up  the  further 
sections  of  the  study. 


II.  THE  BLOCK  STUDY. 

The  central  part  of  the  Family  Study  is  the  survey  of  all  families, 
predominantly  wage-earning,  in  forty-one  blocks  in  Chicago.  Schedules 
were  also  obtained  from  a  few  other  blocks  which  were  not  completely 
canvassed.  Inasmuch  as  the  families  were  taken  as  reached  by  the  inves- 
tigators, these  were  included  with  the  schedules  of  the  blocks  completely 
canvassed.  The  total  number  of  block  families  from  which  schedules 
were  obtained  is  3,048  with  12,450  members.  The  object  of  this  division 
of  the  study  was  to  obtain  from  wage-earning  families  data  upon  the 
extent,  the  duration  and  the  cost  of  sickness;  the  nature,  the  scope  and 
the  costs  of  medical  care  in  the_home,  at  the  dispensary  and  in  the 
hospital ;  and  the  kind  and  the  extent  of  existing  provision  and  protection 
against  the  risks  of  JTsabling  sickness  and  death.  I 

The  mode  of  selection  and  the  social  statistic^  of  the  blocks  have  al- 
ready been  set  forth  in  the  introduction.  The  families  studied  appear 
to  be  not  unrepresentative  of  the  wage-earning  group  in  Chicago  in 
distribution  by  age,  sex,  naticmality,  composition  and  economic^  status. 
In  the  tables  which  present  the  findings  of  the  study  in  regard  to  costs, 
treatment  and  protection  from  risks  of  sickness,  the  data  will  be  analyzed 
with  reference  either  to  nationality  or  to  economic  status.     Since  it  was 


200 

not  feasible  for  technical  reasons  to  present  the  data  to  the  reader  accord- 
ing to  both  nationality  and  economic  status,  a  table  showing  variations 
in  economic  status  by  nationality  is  introduced  at  this  point. 

A  study  of  Table  5  on  the  opposite  page  indicates  wide  differences 
in  economic  status  by  nationality  and  will  be  found  of  value  for  reference 
in  connection  with  later  tables.  The  largest  proportion  of  families 
assigned  to  Class  A  is  found  among  the  Scandinavian  (70.7  per  cent), 
followed  by  United  States  White  (62.9  per  cent),  Bohemian  (59.3  per 
cent),  United  States  Colored  (58.4  per  cent),  German  (56.7  per  cent), 
Irish  (56.6  per  cent),  Pole  (53.8  per  cent),  "Other N'ationalities"  (52.4 
per  cent),  Lithuanian  (50.3  per  cent),  Italian  (37.3  per  cent),  and  Jew 
.(32.6  per  cent).  In  Class  B,  with  meager  incomes,  the  highest  pro- 
portion of  families  by  nationality  is  among  the  Italians  (29.4  per  cent), 
followed  by  the  Poles  (29.3  per  cent),  Jews  (24.8  per  cent),  Lithuanians 
(24.0  per  cent).  United  States  Colored  (21.9  per  cent),  "Other  N'ational- 
ities"  (21.3  per  cent),  Bohemians  (19.3  per  cent),  Irish  (17.8  per  cent), 
United  States  White  (15.2  per  cent),  Germans  (15.0  per  cent),  and 
Scandinavians  (10.3  per  cent).  In  Class  C,  with  deficient  incomes,  the 
largest  proportion  in  the  blocks  studied  is  among  the  Italians  (23.0  per 
cent),  then,  Irish  (14.0  per  cent),  Jews  (10.6  per  cent),  Poles  (9.2  per 
cent),  United  States  Colored  (9.1  per  cent),  Germans  (8.3  per  cent), 
Bohemians  (7.8  per  cent).  United  States  Whites  (7.3  per  cent),  "Other 
Nationalities"  (7.1  per  cent),  Lithuanians  (5.1  per  cent),  and  Scandi- 
navians (4.7  per  cent).  In  Class  0,  or  the  families  where  the  normal 
breadwinner  is  working  "on  his  own  account,"  the  Jews  contribute  by  far 
a  greater  proportion  of  their  families  (25.2  per  cent)  than  any  other 
nationality.  They  are  followed  by  Lithuanians  (15.4  per  cent),  "Other 
Nationalities"  (13.8  per  cent),  Germans  (10.0  per  cent).  United  States 
Whites  (8.4  per  cent), Scandinavians  (7.8  per  cent),  Italians  (6.3  per 
cent),  Bohemians  and  Irish  (each  6.2  per  cent),  Poles  (4.2  per  cent), 
and  United  States  Colored  (3.3  per  cent).  Although  the  number  of 
families  in  Class  D,  those  not  reporting  family 'income  completely,  is 
too  small  for  generalization,  ^t  is  important  to  note  that  the  highest 
proportion  (5.8)  is  with  United  States  Colored,  and  the  lowest  pro- 
portion (1.8  per  cent)  is  with  the  Jews.  The  number  of  families  in 
Class  R,  "retired,"  is  too  small  to  permit  of  comparisons  by  nationality. 

Whether  or  not  the  distribution  by  economic  status  of  the  families 
of  different  nationalities  in  wage-earning  residential  areas  of  Chicago 
corresponds  to  that  of  Table  5,  is  of  little  consequence.  What  Table  5 
exhibits  is  the  relative  proportion,  distributed  by  nativity  and  race  ac- 
cording to  economic  status,  of  families  visited  in  the  Block  Study. 
Among 'these  3,048  families  it  is  probably  safe  to  say  that  the  Scandi- 
navian and  the  United  States  White  are,  relatively  speaking,  well-to-do; 
that  the  Italian,  Pole,  Jew  and  Lithuanian  have  approximately  one- 
fourth  of  their  number  in  meager  circumstances;  that  with  the  Italian 
and  the  Irish  about  one-fourth  and  one-seventh  of  their  families,  re- 
spectively, are  in  poverty ;  that  in  one-fourth  of  the  Jewish  families  and 
one-seventh  of  the  Lithuanian  families  the  normal  bread-winner  is  work- 
ing "on  his  own  account." 


201 


TABLE  5 — NUMBER  AND  PER  CENT  OF  FAMILIES  IN  THE  BLOCK  STUDY 
CLASSIFIED  BY  NATIONALITY  AND  BY  ECONOMIC  STATUS. 


CO 
1 

O 
ki 

1 

Economic  status  of  the  family. 

Nativity  or  race  of  the 

Class  A. 

Class  B. 

Class  C. 

Class  D. 

Class  0. 

Class  R. 

head  of  the  family. 

a 

iz; 

a 

4.S 
© 

o 

© 
Ph 

a 

© 

o 

t-l 
© 

a 

© 
o 

© 
Pn 

Xi 

© 

© 

© 

a 

2 

•1^ 

s 

All  families 

3,048 

1,687 

55.3 

631 

20.7 

280 

9.2 

110 

3.6 

267 

8.8 

73 

2.4 

United  States,  white 
United    States,    col- 
ored   

644 

274 
243 
240 
129 
204 
218 
117 
522 
232 
225 

405 

160 

144 

136 

73 

76 

71 

59 

281 

164 

118 

62.9 

58.4 
59.3 
56.7 
56.6 
37.3 
32.6 
50.3 
53.8 
70.7 
52.4 

98 

60 
47 
36 
23 
60 
54 
28 
153 
24 
48 

15.2 

21.9 
19.3 
15.0 
17.8 
29.4 
24.8 
24.0 
29.3 
10.3 
21.3 

,       47 

25 
19 
20 
18 
47 
23 
6 
48 
11 
16 

7.3 

9.1 

7.8 

8.3 

14.0 

23.0 

10.6 

5.1 

9.2 

4.7 

7.1 

26 

16 

12 

10 

4 

6 

4 

5 

12 

5 

10 

4.0 

5.8 
4.9 
4.2 
3.1 
2.9 
1.8 
4.3 
2.3 
2.2 
4.4 

54 

9 
15 
24 

8 
13 
55 
18 
22 
18 
31 

8.4 

3.3 
6.2 

10.0 
6.2 
6.3 

2.5.2 

15.4 
4.2 
7.8 

13.8 

14 

4 
6 

14 
3 
2 

11 
1 
6 

10 
2 

2.2 
1.5 

Bohemian 

2.5 

German 

5.8 

Irish 

2.3 

Italian 

1.0 

Jewish 

5.0 

Lithuanian 

.9 

Pohsh 

1.2 

Scandinavian 

Other 

4.3 
.9 

202 

The  data  secured  upon  the  problem  of  sickness  in  the  block  study 
will  be  presented  here  under  four  heads: 

(1)  Sickness  among  Chicago  wage-earners. 

(2)  The  cost  of  sickness. 

(3)  The  care  of  the  sick.  /'    * 

(4)  Existing  protection  against  risks. 

(.1)   Sickness  Among  Families  in  Wage-earning  Blocks. 

Sickness  as  viewed  by  the  Family  Study  usually  denotes  disabling 
illness  involving  cessation  of  work  or  confinement  to  the  house  for  a 
period  of  at  least  a  week.  Illnesses  of  a  duration  of  less  than  a  week, 
including  many  minor  disabilities,  were  usually  excluded  either  by  the 
agent  in  the  field  or  in  the  editing  of  the  schedules.  Exceptions  were 
made,  however,  in  the  case  of  serious  shorter  illness,  as  for  example, 
bad  tonsils  requiring  removal,  and  in  other  cases,  where  a  physician  was 
called.  Moreover,  all  cases  of  tuberculosis  and  serious  chronic  diseases 
were  recorded  whether  they  resulted  in  complete  disability  or  not. 

Table  6  (on  the  opposite  page)  presents  the  incidence  of  disabling 
illness  analyzed  by  economic  status  of  the  family  and  by  the  industrial 
status  of  its  members  as  gainfully  or  non-gainfully  occupied.  There  was 
disabling  sickness  in  2,005  or  65.8  per  cent  of  the  3,048  families  living 
in  the  blocks  studied.  The  variations  in  the  relative  number  of  cases 
of  illness  in  the  families  by  economic  status  is  significant.  Illness 
appeared  in  63.4  per  cent  of  families  in  Class  A  with  the  higher  incomes, 
73.0  per  cent  of  families  in  Class  B  with  meager  incomes,  76.0  per  cent 
of  families  in  Class  C  with  deficient  incomes,  in  only  56.9  per  cent  of 
families  in  Class  0  "on  own  account,"  and  in  69.9  per  cent  of  families 
in  Class  R  "retired."  However,  when  the  total  number  sick  is  com- 
pared with  total  number  in  the  familv,  we  discover  more  uniform  ratios 
by  economic  status  in  Classes  A,  B,  and  C,  with  the  respective  per- 
centages of  28.9,  27.0  and  28.0.  The  number  of  persons  sick  in  Class 
0  families  was  smaller  (23.4  per  cent).  The  highest  proportion  of 
persons  sick  is  found  in  Class  R  (42.6  per  cent).  This  seems  to  indicate 
that  so  far  as  wage-earning  families  are  concerned,  i.  e.  those  in  Classes 
A,  B,  and  C,  there  was  practically  no  difference  in  the  proportion  of  the 
members  ill  although  the  percentage  of  families  in  which  there  was  sick- 
ness varied  directly  with  the  lower  economic  status. 

The  right  half  of  the  table  shows  relative  proportions  of  families 
with  sickness  experience  according  to  the  industrial  status  of  its  members 
as  gainfully  or  non-gainfully  occupied.  The  largest  proportion  of  fami- 
lies in  which  one  or  more  persons  gainfully  occupied  were  sick  is  naturally 
found  in  Class  R  (100  per  cent),  followed  by  Class  0  (47.4  per  cent), 
Class  C  (45.5  per  cent),  Class  B,  (45.3  per  cent),  and  Class  A  (41.6 
per  cent).  These  percentages  refer  to  the  proportion  of  families  in 
which  there  was  illness  to  total  families.  Considering  only  wage-earning 
families  where  complete  income  was  reported,  or  groups  A,  B,  and  C, 
it  was  found  that  the  number  of  families  in  which  one  or  more  persons 
gainfully  occupied  were  sick  was  in  Class  A,  625,  or  37.0  per  cent;  in 


203 


TABLE  6— FAMILIES  IN  WHICH  THERE  IS  SICKNESS  ANALYZED  BY 
ECONOMIC  STATUS  AND  BY  THE  INDUSTRIAL  STATUS  OF  ITS 
MEMBERS. 


1 

a 

Sickness  in  the  family  according  to  the 

Families  in 

5 

CO 

Members 

industrial  status  of  its  members. 

Families  in 

Families  in 

Families  in 

which 

there 

fe 

sick. 

which 

which  only 
members 
gainfully 
occupied 
are  sick. 

which  only 

Economic  status  of  the 
family. 

a 

a 

O 

is  sickness. 

Xi 

a 
a 

members 

gainfully 

occupied 

and  others 

members 

non- 
gain  fully 
occupied 

a 

3 

are  sick. 

are  sick. 

a 

3 

i^ 

-«>^ 

u 

-M 

* 

4J 

C 

1.^ 

• 

a 

a 

d 

d   . 

<o 

d 

<u 

d 

o 

d 

« 

(3 

Xi 

<o 

"    CO 

X> 

© 

X> 

o 

Xi 

o 

pQ 

« 

as 

a 

3 

a 

3 

1 

a 

d 

a 

9 

H 

^ 

PUl 

^ 

^ 

P^ 

^ 

Pli 

;z; 

Pm 

^ 

PLh 

Block  study 

3,048 

2,005 

65.8 

12,450 

3,450 

27.7 

543 

27.1 

571 

28.5 

891 

44.4 

Class  A 

1,687 
631 

1,070 
461 

63.4 
73.i) 

6,090 
3,084 

1,763 

832 

28.9 
27.0 

263 
151 

24.6 
32.8 

362 
101 

33.8 
21.9 

445 
209 

41.6 

Class  B  

45.3 

Class  C 

280 

110 

267 

73 

304 

213 
58 

152 
51 

297 

76.0 
52.7 
56.9 
69.9 

97.7 

1,519 
466 

1,122 
169 

1,550 

426 
94 

263 
72 

710 

28.0 
20.2 

45.8 

71 
23 
35 

33.3 
39.7 
23.0 

45 
18 
45 

21.1 
31.0 
29.6 

97 
17 

72 
51 

176 

45.5 

Class  D 

29.3 

Class  O  

47.4 

Class  R 

tOD.O 

Nursing  service  study. . 

104 

35.0 

17 

5.7 

Co 

59.2 

Class  A 

132 
91 

48 
2 

25 
6 

628 

127 
90 
48 

2 
24 

6 

613 

96.2 

98.9 

100.0 

100.0 

96.0 

100.0 

97.6 

568 
508 
321 

11 
126 

16 

3,475 

271 

225 

141 

5 

59 

9 

1,546 

47.7 
44.3 
43.9 
45.5 
46.8 
56.3 

44.5 

46 

30 

17 

2 

9 

36.2 
33.3 
35.4 
100.0 
37.5 

11 
5 
1 

8.7 
5.6 
2.1 

70 
55 
30 

55.1 

Class  B 

61.1 

Class  C 

62.5 

Class  D 

Class  O  

15 
6 

95 

62.5 

Class  R 

100.0 

Charity  study 

428 

69.8 

90 

14.7 

15.5 

204 

Class  B,  252  persons,  or  40.0  per  cent;  in  Class  C,  116,  or  41.4  per  cent; 
in  Class  0,  80  persons,  or  30.0  per  cent. 

The  proportion  of  wage-earners  who  were  sick  to  all  employed  per- 
sons as  compared  with  similar  figures  for  all  persons  in  wage-earning 
families  is  of  interest.  Of  the  11,159  persons  in  wage-earning  families, 
3,115  or  27.9  per  cent  were  reported  as  ill.  Of  those  occupied,  1,222  or 
27.3  per  cent  of  4,474  Wage-earners  were  reported  with  disabling  sickness, 
as  against  1,893  or  28.3  per  cent  of  6,685  persons  not  gainfully  occupied 
in  wage-earning  families. 

The  number  and  proportion  by  economic  status,  of  wage-earners 
sick  to  their  total  number  is  indicated  as  follows : 


Normal  economic  status. 

Total  number 

of 
wage  earners. 

Number  sick. 

Per  cent  sick. 

Class  A 

2,770 
937 
373 
215 
160 
19 

746 

273 

139 

36 

27 

1 

26.9 

Class  B 

29.1 

Class  C 

37.3 

Class  D 

16.7 

Class  0 

16.9 

Class  R 

5.3 

Total 

4,474 

1,222 

27.3 

According  to  these  figures,  the  proportion  of  wage-earners  sick 
increased  with  descent  in  the  scale  of  economic  condition.  The  pro- 
portion of  wage-earners  sick  in  Class  C  was  over  one-third  larger  than 
in  Class  A.  This  is  an  interesting  result  in  view,  of  the  fact  that  the 
members  of  the  poorer  families  as  a  whole  showed  no  excess  in  the  rate 
of  sickness.  Perhaps  the  failure  to  give  attention  to  cases  of  actual 
sickness  among  non-wage-earners  in  the  poorer  families  explains  the  ap- 
parently contradictory  results  arrived  at. 

No  comparison  has  been  attempted  between  the  relative  amounts 
of  sickness  among  the  wage-earners  and  those  working  on  their  own 
account.  As  the  blocks  were  selected  to  be  representative  of  wage-earn- 
ing families,  it  is  obvious  that  they  would  not  be  typical  of  the  self- 
employed  group.  The  agents  of  the  Commission  in  the  Block  Study 
report  that  families  with  members  working  on  their  own  account  in  these 
blocks  are  predominantly  junk  dealers,  peddlers,  proprietors  of  small 
shops  in  the  block,  of  little  or  no  higher  economic  standing  than  their 
wage-earning  neighbors.  N"ot  infrequently,  as  where  a  wage-earner  be- 
comes a  small  proprietor  because  of  age  or  inability  to  stand  the  regular 
strain  of  industry,  the  economic  standing  of  the  family  "on  own  account 
is  lower  than  for  the  average  wage-earning  family. 


?? 


(2)   Sickness  Costs  m  Families  in  Wage-earning  Blocks. 

Sickness  costs  are  of  two  kinds:  direct  and  indirect.  The  direct 
costs  are  the  outlays  involving  additional  family  expenditure  caused  by 
illness.  The  cost  of  medicine,  the  compensation  for  the  attendance  of 
the  physician,  expenditures  for  nursing  service,  for  hospital  care,  dis- 
pensary fees,  are  items  which  severally,  or  in  combination,  are  involved 
in  practically  every  case  of  illness.     These  direct  costs  of  sickness  are 


205 

significant  in  the  econoni}^  of  the  wage-earning  family  because  they  are 
seldom  anticipated  or  included  in  the  budget  of  expenditure. 

The  indirect  costs  of  sickness  are  many.  Two  costs,  however,  are 
outstanding,  that  of  the  loss  of  wages  consequent  upon  enforced  unem- 
ployment during  illness,  and  that  of  reduced  earning  power  because  of 
permanently  impaired  ph^^sical  condition.  This  lowered  productive 
efficiency  of  the  wage-earner  is  real  but  difficult  to  determine  statistically 
in  pecuniary  terms.  It  can  be  measured  in  individual  cases,  but  no  data 
exist  for  computing  in  dollars  and  cents  the  loss  to  wage-earners  and  to» 
society  of  decreased  industrial  efficiency  caused  by  illness  not  completely 
recovered  from.  Wage  losses  from  sickness  may,  however,  be  readily 
determined  from  the  rate  of  pay  at  the  time  of  leaving  work  and  from 
the  number  of  weeks  ill.  The  indirect  costs  of  sickness  will,  therefore, 
be  understood  in  the  following  discussion  to  refer  only  to  the  loss  of 
wages  caused  by  sickness. 

The  costs  of  sickness  among  wage-earners  and  their  families  may  be 
considered  separately  for  the  individual  and  for  the  family. 

Illness  of  the  wage-earner  involves  in  general  both  the  direct  and 
the  indirect  costs  of  sickness.  Sickness  of  the  non-gainfully  occupied 
involves  only  direct  costs.  In  disabling  illness  of  the  "self-employed" 
indirect  losses  may  often  result,  but  they  are  not  readily  ascertainable 
and  have  here  been  left  out  of  consideration. 

Table  7  shows  individual  sickness  costs  according  to  the  industrial 
status  of  the  person  sick,  as  wage-earner,  "self-employed"  or  non-gain- 
fully occupied. 

Of  the  3,450  individuals  sick,  2,585  reporting  sickness  costs  in  full 
give  a  total  loss  from  sickness  4)f  $184,728,  or  an  average  of  $71.46  per 
person  ill.  Since  for  wage-earners  only  are  indirect  costs  of  sickness 
present  or  ascertainable,  the  sickness  costs  will  be  given  separately  for 
wage-earners,  for  "self-employed"  and  for  the  non-gainfullv  occupied. 

The  proportion  of  the  sick  with  illness  costs  varied  significantly. 
Eleven  hundred,  or  90.0  per  cent,  of  1,222  wage-earners;  64,  or  65.3  per 
cent,  of  98  "self-employed:"  1,573,  or  74.1  per  cent  of  2,130  non-gain- 
fully occupied  who  were  sick  during  the  year  reported  sickness  costs. 

Of  the  1,222  wage-earners  sick  1,100  had  sickness  costs;  but  only 
1,019  reporting  in  full  gave  the  total  indirect  costs  of  illness  (through 
wages  lost)  as  $102,962  and  the  total  of  direct  outlays  for  sickness  as 
$24,749.  This  means  that  to  every  dollar  lost  by  absence  from  work  be- 
cause of  sickness  tAventy-four  cents  must  be  added  for  costs  of  medical 
treatment  and  care. 

The  total  direct  outlays  for  sickness  for  61  (64  with  costs  of  the 
98  sick)  "self-employed"  reporting  in  full  were  $3,037;  for  1,505  (1,573 
with  costs  of  the  2,130  sick)  non-gainfully  occupied  reporting  in  full, 
$53,980. 

For  the  wage-earning  group  a  more  intensive  study  was  made  of 
time  and  wages  lost  and  cost  of  sickness.  The  results  are  shown  in 
Table  8. 

Of  the  1,222  sick  wage-earners,  937,  or  76.7  per  cent,  lost  time  on 
account  of  sickness;  285,  or  23.3  per  cent  either  did  not  lose  as  much 


206 


TABLE  7— INDIVIDUAL.  SICKNESS  COSTS  BY  INDUSTRIAL,  STATUS  OF 
PERSONS  SICK  IN  THE  BLOCK,  NURSING  SERVICE  AND  CHARITY 
GROUPS. 


Block 
study. 


Nursing 

service 

study. 


Charity 
study. 


Total  number  of  individuals  sick 

Total  number  of  wage-earners  sick 

Total  number  of  ''self-employed  "  sick 

Total  number  non-gainfuily  occupied  sick 

Total  number  of  individuals  with  sic&iess  costs 

Total  number  reporting  costs  in  fuU 

Total  costs  reported  in  full 

Wage-earners — 

Number  with  costs 

Number  reporting  costs  in  full 

Sickness  costs 

Direct  outlays 

Lost  wages 

"Self-employed" — 

Number  with  costs 

Number  reporting  costs  in  full 

Sickness  costs  (direct  outlays) 

Non-gainfully  occupied — 

Number  with  costs 

Number  reporting  costs  in  full 

Sickness  costs  (direct  outlays) 


3,450 
1,222 
98 
2,130 
2,737 
2,585 
$184,728 

1,100 

1,019 

$127,711 


$  24,749 
102,962 


64 

61 

$3,037 


1,573 

1,505 

$53,980 


710 
148 
10 
552 
576 
555 
$35,600 

129 

125 

$16, 780 


$  5,066 
11,714 


3 

3 
$35 


444 

427 

$18,785 


1,546 
602 
22 
922 
708 
632 
$110,764 

501 
447 

$104, 158 


$  5,530 
98,628 


6 
3 

$52 


201 

182 
^,554 


TABLE   8 — LOSS   OF  TIME   AND  WAGES   CAUSED   BY   SICKNESS   OF  WAGE- 
EARNERS    REPORTING    COMPLETELY. 


Block 
study. 


Nursing 

service 

study. 


Charity 
study. 


Wage-earners— 

Total  number  of  wage-earners 

Number  of  wage-earners  sick 

Per  cent  of  wage-earners  sick 

Number  losing  more  than  one  week's  time  because  of  sickness 
Number  losing  less  than  one  week's  time 

Time  and  wages  lost — 

Number  of  wage-earners  losing  more  than  one  week's  time  and 

reporting  completely 

Total  number  of  weeks  lost  from  work 

Total  earnings  from  wages 

Total  wages  lost 


4,474 

1,222 

27.3 

937 

285 


901 


6,632 
$676,087 
$107,338 


409 
143 
35.0 
116 
27 


115 

737 
$93, 986 
$12,213 


878 
602 
68.6 
494 
108 


450 

7,824 
$183,841 
$104, 493 


207 

time  as  a  week  or  continued  at  work  although  ill.  Of  those  away  from 
work  for  a  period  longer  than  a  week  because  of  sickness,  901  reported 
6,632  weeks  and  $107,338  in  wages  lost.  This  means  an  average  loss 
of  time  of  7.3  weeks  and  an  average  wage  loss  of  $119.13  (15.9  per  cent  of 
wages  received)  for  those  making  complete  reports. 

A  special  study  was  made  of  the  direct  costs  of  sickness  as  compared 
with  earnings  from  wages  of  685  wage-earners  who  were  sick  during  the 
year.  They  reported  for  the  year  a  total  wage  income  of  $492,883  and 
a  total  cost  of  medical  treatment  and  of  medicine  of  $24,411  or  an  ex- 
penditure of  5.0  per  cent  of  earnings  from  wages  to  meet  the  direct  out- 
lays of  illness.  The  average  cost  ,of  sickness  so  far  as  direct  outlays  are 
concerned  for  the  685  sick  wage-earners  making  complete  returns  was 
$35.64.  By  reference  to  the  figures  presented  in  Table  7  it  is  prac- 
ticable to  compare  the  direct  outlays  involved  in  sickness  for  persons 
sick  by  industrial  status  as  wage-earner,  "self-employed,"  or  non-gainf uUy 
occupied,  as  follows: 


Industrial  status. 


Number 

persons  sick 

reporting 

direct 

outlays. 


Direct 

outlays 

reported. 


Average 
outlay  for 
sickness. 


Wage  earner 

Self-employed 

Non-gain  fully  occupied 


685 

61 

1,505 


$24,411.00 

3,037.00 

53,980.00 


*$35. 64 
49.79 
35.87 


*  Apparently  the  cost   of  a  case  of  sickness  so  far  as  direct  outlays  Is  con- 
cerned is   the  same   for  the  wage-earner  as  for  the   non-gainfully  occupied. 

Up  to  this  point  we  have  considered  total  and  average  losses.  A 
pertinent  consideration  is,  of  course,  the  proportion  of  losses  of  different 
amounts.  Table  9  presents  the  number  of  sick  wage-earners  losing  differ- 
ent proportions  of  their  wage  income.  The  number  of  wage-earners  who 
were  sick  during  the  year  was  1,222,  those  losing  as  much  as  a  weeks's 
time  from  illness  was  937,^  those  losing  less  than  a  week  including  those 
losing  no  time  because  of  illness  was  285.  Of  the  1,151  sick  wage- 
earners  reporting  in  regard  to  weeks  and  wages  lost  by  illness,  250  reported 
no  loss  for  so  long  a  period  as  one  week,  and  901  reported  a  loss  of  wage- 
income  for  a  week  or  more.  Of  the  901  who  lost  wages  for  a  week  or 
more  286  or  31.7  per  cent,  lost  less  than  5  per  cent  of  annual  earnings; 
221,  or  24.4  per  cent,  lost  5  but  less  than  10  per  cent;  82,  or  9.1  per  cent, 
lost  10  but  less  than  15  per  cent;  99,  or  11.0  per  cent,  lost  15  but  less 
than  20  per  cent;  83,  or  9.2  per  cent,  lost  20  but  less  than  30  per  cent; 
46,  or  5.1  per  cent,  lost  30  but  less  than  40  per  cent;  17,  or  1.9  per  cent, 
lost  40  but  less  than  50  per  cent ;  52,  or  5.8  per  cent,  lost  50  but  less  than 
75  per  cent;  15,  or  1.7  per  cent,  lost  75  per  cent  or  more. 

The  cost  of  the  wage-earner's  sickness  is  only  a  part,  although  a 
major  part,  of  the  cost  of  sickness  which  he  bears.  The  wage-earner  is 
a  member  of  the  family  group,  and  the  cost  of  sickness  of  its  members 
not  gainfully  occupied  falls  upon  him. 

3 /See  Table  8,  p.  206. 


208 


r^ 


.^ 


TABLE   9— WAGE   LOSSES   OF   SICK  WAGE-EARNERS. 


Block 
study. 


Nursing 

service 

study. 


Charity 
study. 


Wage  earners — 

Total  number 

Total  number  sick 

Total  number  reporting  weeks  and  wages  lost 

Number  losing  percentage  of  weeks  and  wages — 

None* 

Less  than  5  per  cent 

5  to  9  per  cent 

10  to  14  per  cent 

15  to  19  per  cent 

20  to  29  per  cent 

30  to  39  per  cent 

40  to  49  per  cent 

50  to  74  per  cent 

75  per  cent  and  over 


4,474 
1,222 
1,151 


250 
286 
221 
82 
99 
83 
46 
17 
52 
15 


409 
143 
141 


26 

41 

23 

17 

10 

13 

6 

2 

3 


878 
602 
540 


90 
40 
61 
31 
39 
58 
56 
29 
73 
63 


•  None  means  that  at  no  one  time  in  the  course  of  the  year  did  the  wage- 
earners  lose  as  much  time  as  six  days.  Hence  among  these  cases  are  an  unknown 
number  who  did  lose  time  and  perhaps  wages,  possibly  for  much  more  than  a 
week,  but  who  did  not  lose  as  much  as  six  working  days  consecutively.  This  same 
factor  should  be  held  in  mind  in  case  of  those  reporting  more  than  one  week's 
lost  time,  for  the  lost  time  reported  does  not  include  such  losses  as  proved  to  be 
of  less  than  a  week's  duration. 


209 

The  data  on  famil}^  sickness  costs  were  tabulated  in  several  different 
ways  in  order  to  answer  the  following  inquiries : 

(1)  What  is  the  range  of  sickness  costs?  What  is  their  variation 
by  economic  status? 

(2)  What  is  the  relation  of  average  family  sickness  cost  to  capacity 
to  bear  the  burden  as  indicated  by  economic  status  ? 

(3)  ^Yh.8it  is  the  distribution  of  family  sickness  costs  by  specific 
outlays  ? 

Range  of  sickness  costs  by  economic  status. — The  distribution  of 
sickness  costs  among  the  families  is  shown  in  Table  10.  Of  the  1,909 
block  families  reporting  losses  from  illness,  978  reported  costs  less  than 
$50  and  931  reported  costs  of  $50  and  over.  That  nearly  one-half  of 
these  families  had  sickness  costs  of  $50  and  more  indicates  the  serious 
financial  strain  connected  with  sickness.  A  careful  studv  of  the  table 
brings  out  the  further  fact  that  regardless  of  the  economic  status  of  the 
families,  or  their  relative  ability  to  pay,  variations  in  sickness  costs  are 
remarkably  uniform. 

Average  cost  of  family  sickness  analyzed  by  capacity  to  carry. — The 
average  cost  of  family  sickness  may  be  derived  from  the  figures  presented 
in  Table  11.  Seventeen-hundred-forty-four,  or  67.1  per  cent  of  the 
2,598  block  wage-earning  families  in  Classes  A,  B,  and  C  reported  dis- 
abling sickness.  The  1,667  wage-earning  families  in  the  block  study 
reporting  sickness  losses  in  full  had  total  costs  of  illness  amounting  to 
$163,340,  or  an  average  of  $97.98.  The  sickness  cost  was  8.4  per  cent 
of  their  wages  and  7.5  per  cent  of  their  incomes.  Of  this  amount  the 
average  per  family  of  direct  outlays  was  $43.03,  of  lost  wages  $54.95. 
Taken  by  economic  status  the  average  sickness  cost  was  for  families  in 
Class  A  for  direct  outlavs  $45.68,  for  lost  wages  $57.05,  or  a  total  of 
$102.73;  for  families  iii  Class  B,  for  direct  outlays  $35.84,  for  lost 
wages  $47.03,  or  a  total  of  $82.87;  for  families  in  Class  C,  for  direct 
outlays  $45.18,  for  lost  wages  $62.15,  or  a  total  of  $107.33.  Evidently, 
families  in  Class  B  were  in  a  favorable  situation  from  the  standpoint 
of  the  average  amount  of  illness  costs  both  in  regard  to  direct  outlays 
and  lost  wages. 

Two  considerations  are  probably  sufficient  for  explanation.  Class 
B  families  are  in  a  more  favorable  age-group  relative  to  sickness  than 
families  in  Class  C  and  perhaps  also  than  families  in  Class  A.  Then, 
too,  the  longer  duration  of  illness  in  Class  C  families  and  the  superior 
pecuniary  capacity  of  Class  A  families  to  secure  medical  treatment  re- 
sulted in  comparatively  lowered  sickness  costs  in  Class  B.  Of  more 
significance  is  the  fact  that  the  average  sickness  cost  of  families  in 
Class  C  was  $4.60  higher  than  in  Class  A. 

In  determining  the  actual  weight  of  this  somewhat  heavier  absolute 
burden  of  sickness  cost  upon  Class  C  families,  it  is  desirable  to  take 
into  account  the  capacity  to  carry  sickness  costs  as  measured  by  average 
total  family  income,  and  by  average  income  from  other  sources  than 
wages. 

The  average  family  income  of  the  1,667  wage-earning  families  re- 
turning complete  information  is  $1,297.96.     This  is  approximately  $4 
—14  H  I 


210 


TABLE    10 — PECUNIARY    BURDEN    OF    FAMILY    SICKNESS     (DIRECT    OUT- 
LAYS   AND    LOST    WAGES)     BY    ECONOMIC    STATUS. 


o 
o 

Is 
dia 

Total  number  of 
families  with 
sickness. 

Number  with 
costs  reported. 

Distribution  of  family  sickness  costs. 

Economic  status  of  the 
family. 

d 

1 

4 

>— 1 

05 

1 

CO 

o 

g  O 

Block  study 

3,048 

2,005 

1,909 

978 

368 

172 

106 

111 

76 

39 

59 

Class  A 

1,687 
631 
280 
110 

267 
73 

•304 

1,070 

'461 

213 

58 

152 

51 

297 

1,048 
440 
179 

42 
162 

38 

268 

507 
233 
91 
26 
96 
25 

112 

213 
90 
27 

3 
29 

6 

49 

87 
47 
20 

4 
10 

4 

34 

67 

16 

9 

2 

11 

1 

14 

57 

23 

17 

5 

7 

2 

22 

54 

13 

6 

3 

25 
6 
3 
2 
3 

38 

Class  B  

12 

Class  C 

6 

Class  D  

Class  0  

3 

Class  R 

Nursing  service  study 

10 

9 

18 

Class  A  

132 
91 
48 

2 
25 

6 

628 

127 

90 

48 

2 

24 

6 

613 

121 
77 
40 

2 
23 

5 

408 

39 
36 
26 

25 

12 

5 

17 

12 

3 

1 

1 

42 

6 
5 
2 

11 
6 

8 
2 

4 
3 
1 

1 

11 

Class  B 

1 

Class  C 

3 

Class  D  

Class  0 

10 
1 

99 

6 
1 

51 

i 

.      33 

3 
2 

49 

3 

Class  R 

Charity  study 

/ 
43 

34 

57 

TABLE  11— INCOMES  AND  SICKNESS  COSTS  OF  WAGE-EARNING  FAMILIES 
REPORTING  INCOMES  AND  SICKNESS  COSTS  IN  FULL. 


Economic  status  of 
of  family. 


I 

© 

03  © 

H 

©    OT 

Cost  of  sickness. 

otal  number  w 
earning  famili 
with  sickness. 

—1    Xfl 

•^  2 
©;^ 

d  © 

3S 

;d 

■^^ 

R  © 
P  xn 

«^ 

3d 

Od 

d  o 

3 

rect 
utlays. 

t 

CO 

© 

03 

CO 

O+J 

O-w 

o 

.:-i  " 

O 

H 

H 

Eh 

^ 

H 

« 

h5 

Family  incomes. 


03 

O 

E-t  -. 


© 

03 

a 

o 


© 

.d 


Block  study 

Class  A 

Class  B 

Class C 

Nursing  service 
study 

Class  A..... 

Class  B 

Class  C 

Charity  study . . 


1,744 

7,294 

3,021 

1,667 

$163,340 

$71,733 

$91,607 

1,070 
461 
213 

3,932 

2,182 
1,180 

1,763 
832 
426 

1,048 
440 
179 

$107,666 
36,462 
19,212 

$47, 874 

15,771 

8,088 

.$59,792 
20,691 
11,124 

265 

1,380 

637 

245 

33,497 

21,907 

11,590 

127 
90 

48 

563 
506 
311 

271 
225 
141 

121 
80 
44 

$21,403 
8,080 
4,014 

$13,648 
6,388 
1,871 

$7,755 
1,692 
2,143 

554 

3,032 

1,412 

388 

91,308 

12,802 

78,506 

$1,575,496 
457, 525 
130, 747 


311,970 


$183, 696 
89, 434 
38,840 

274,050 


$1,953,439 


$1,399,696 
430,623 
123, 120 


289, 177 


$210,329 


$168,724 
83, 837 
36,616 

252,547 


$175, 800 

26,902 

7,627 


22,793 


$14,972 
5,597 
2,224 

21, 503 


211 

less  than  the  average  income  of  all  wage-earning  families  in  the  block 
study.*  Marked  clifferences  appear  when  comparison  is  made  by  eco- 
nomic status.  The  average  income  per  family  in  Class  A  was  $1,503.34, 
in  Class  B  $1,039.83  and  in  Class  C  $730.43.  Clearly,  then,  an  average 
Class  C  family  ^^ith  little  more  than  one-half  of  the  capacity  (as 
measured  by  income)  to  bear  the  burden  of  sickness  costs,  as  the  average 
family  in  Class  A  is  loaded  with  a  somewhat  larger  pecuniary  loss  due 
to  illness. 

This,  however,  does  not  disclose  the  entire  disadvantage  of  families 
in  Class  C  when  compared  with  those  in  Class  A.  Upon  consideration, 
it  is  apparent  that  families  with  a  higher  proportion,  or  larger  amount, 
of  income  from  other  sources  than  wages  will  be  favorably  situated  with 
reference  to  capacity  to  bear  the  burden  of  sickness  costs.  Income  from 
other  sources,  unlike  wages,  is,  presumably,  undiminished  by  illness. 
One-thousand-forty-eight  families  in  Class  A  reported  total  income  of 
$1,575,496  of  which  $175,800  or  11.2  per  cent,  is  from  other  sources 
than  wages;  440  families  in  Class  B  reported  total  income  of  $457,525  of 
which  $26,902,  or  5.9  per  cent,  was  from  other  sources  than  wages;  179 
families  in- Class  C  reported  total  income  of  $130,747,  of  which  $7,627, 
or  5.8  per  cent,  was  fl'om  othei*  sources  than  wages.  While  the  smaller 
percentage  of  income  from  other  sources  than  wages  to  the  total  family 
income  indicates  the  unfavorable  situation  of  Classes  B  and  C  families 
relative  to  those  in  Class  A,  the  actual  disadvantage  of  families  in 
Classes  B  and  C  is  not  apparent  until  a  comparison  is  made  of  the 
average  annual  income  from  other  sources  than  wages:  families  in  Class 
A  $167.75,"  in  Class  B  $61.14,  in  Class  C  $42.61. 

Distribution  of  family  sickness  costs  hy  specific  outlays. — Of  the 
2,203  families  in  the  Block  Study  with  sickness  costs,  1,909,  according 
to  Table  12,  reported  them,  in  full  and  in  detail.  Thirteen-hundred- 
thirty-eight,  oi:^70.1  per  cent,  employed  physicians  at  a  total  outlay  of 
$60,457,  or  an  average  of  $45.11  per  family;  91,  or  4.8  per  cent,  employed 
a  nurse  at  a  total  expenditure  of  $2,665,  or  an  average  of  $29.29  per 
family;  198,  or  10.4  per  cent,  report  hospital  bills  of  $11,156,  or  an 
average  of  $56.34  per  family;  143,  or  7.5  per  cent,  report  dispensary 
charges  of  $772  or  an  average  of  $5.40  per  family;  1,533,  or  80.3  per 
sent,  report  $24,395  expended  for  medicines,  or  $15.91  per  family; 
-^738,  or  38.7  per  cent,  report  $96,403'  in  lost  wages  because  of  sickness 
or  an  average  of  $130.45  per  family;  221,  or  11.6  per  cent,  report  other 
expenses  in  connection  with  sickness  totaling  $2,721,  or  an  average  of 
$12.31. 

•  Of  every  dollar  of  sickness  costs,  48.6  cents  represented  lost  wages, 
30.4  cents  went  to  services  of  physicians,  12.3  cents  for  medicine,  5.7 
cents  for  hospital  bills,  1.3  cents  to  nursing  service,  0.4  cents  to  dis- 
pensary charges,  and  1.3  cents  to  miscellaneous  outlays. 

An  initial  conclusion  to  be  derived  from  an  examination  of  these 

'data,  and  one  more  likely  than  not  to  be  confirmed  by  further  study,  is 

that  the  detailed  items  do  not  indicate  excessive  costs  and  that  there  is 

evidence,  if  anything,  of  undor-use  rather  than  of  over-use  of  existing 

*See  p.  199. 


212 


TABLE    12— DETAILED   ANALYSIS    OF    COSTS    OF    FAMILY    SICKNESS    FOR 
THE   BLOCK,   THE  NURSING   SERVICE  AND   THE   CHARITY   GROUPS. 


Block 
study. 


Nursing 
service 
study. 


Charity 
study. 


Total  number  of  families 

Number  with  sickness 

Number  with  sickness  costs 

Number  reporting  costs 

Total  sickness  costs  of  families  reporting  costs  completely 

Analysis  of  sickness  costs  of  families  with  complete  reports — 

Families  with  expenditure  for  physician 

Amount 

Per  cent  of  total  sickness  cost 

Families  with  expenditure  for  nurse 

Amount 

Per  cent  of  total  sickness  cost 

Families  with  expenditure  for  hospital  service 

Amount 

Per  cent  of  total  sickness  cost 

Families  with  paid  dispensary  treatment 

Amount 

Per  cent  of  total  sickness  cost 

Families  with  expenditure  for  medicine 

Amount 

Per  cent  of  total  sickness  cost 

Families  with  lost  wages 

Amount 

Per  cent 

Families  with  other  sickness  cost 

Amount 

Per  cent 


3,048 
2,005 
2,203 
1,909 
$198, 569 

1,338 

$60, 457 

30.4 

91 

$2,665 

1.3 

198 

$11, 156 

5.7 

143 

$772 

.4 

1,533 

$24, 395 

12.3 

738 

$96,403 

48.6 

221 

$2,721 

1.3 


304 
297 
283 
268 
$.39,622 

247 

$15,377 

38.8 

96 

$2, 167 

5.5 

60 

$4, 828 

12.2 

105 

$505 

1.3 

242 

$4,696 

11.9 

97 

$11,843 

29.9 

11 

$206 

.5 


628 
613 
563 

408 
$99,733 

168 

$6,650 

6.7 

8 

1146 

.1 

46 

$3,152 

3.2 

19 

$151 

.2 

210 

$4,486 

4.5 

333 

$84,834 

85.0 

35 

$314 

.3 


213 

facilities  for  medical  treatment.     The  discussion  of  the  care  of  the  sick, 
however,  is  the  next  point  to  be  taken  up. 

In  respect  to  family  sickness  costs,  the  data  examined  indicate  first, 
that  where  there  is  sickness,  the  average  burden  is  just  under  $100  in 
Chicago  wage-earning  families;  secondly,  that  it  is  higher  in  Class  C 
than  in  Class  A,  and  much  higher  than  in  Class  B ;  thirdly,  that  Class 
C  families  are  less  than  three-fourths  as  able  as  families  in  Class  B, 
and  not  half  as  able  as  families  in  Class  A  to  assume  sickness  losses. 

(3)   The  Care  of  the  Side 

The  costs  of  the  different  types  of  medical  care  of  the  sick  in  the 
block  study  have  already  been  presented.  The  point  of  emphasis  here 
is  upon  medical  facilities  available  and  utilized  by  families  in  wage- 
earning  residence  areas  in  Chicago.  Table  13,  on  ^age  212,  offers  data 
upon  both  paid  and  free  medical  service  obtained  by  these  families  last 
year.  The  attendance  of  physician,  nursing  service,  hospital  care,  dis- 
pensary service,  medicine  are  forms  of  medical  treatment  to  be  discussed. 

Attendance  of  physician. — The-  directory  of  the  American  Medical 
Association  reports  5,667  physicians  in  Cook  County  September,  1918. 
Even  making  allowance  for  the  large  number  in  1917-18  in  the  military 
service  of  the  United  States,  the  number  remaining  was  probably  suf- 
ficient to  meet  the  ordinary  sickness  demands  of  the  civilian  population 
of  the  city.  Yet  of  1,909  families  (of  a  total  of  2,005  with  sickness) 
reporting  sickness  cost,  571,  or  29.9  per  cent,  were  without  the  paid 
service  of  an  attending  physician  for  disabling  illness.  In  273  families, 
the  free  services  of  a  physician  were  secured.  While  a  small  number  of 
families  obtained  both  free  and  paid  service,  it  may  be  stated  that  in  up- 
ward of  298  families,  or  15.6  per  cent,^  that  the  person  sick  was  (unless 
treated  at  a  dispensary  or  hospital)  without  either  free  or  paid  attend- 
ance by  a  physician. 

Nursing  service. — 'The  nursing  service  at  present  available  to  wage- 
earning  families  in  Chicago  is  of  three  types.  The  first  is  that  of  the 
registered  or  practical  nurse  to  be  obtained  at  a  daily  or  weekly  rate  in 
almost  all  cases  beyond  the  resources  of  the  wage-earning  family.  The 
second  is  that  offered  in  connection  with  the  industrial  policies  of  the 
Metropolitan  Life  Insurance  Company  and  occasionally  in  connection 
Kvith  benefit  provision  of  other  insurance  carriers  and  business  firms, 
by  which  limited  nursing  service  is  provided  without  cost,  or  for  a  nomi- 
nal sum.  The  third  kind  is  that  of  the  Visiting  Nurse  Association  or 
of  the  field  work  of  the  Infant  Welfare  Society,  of  the  School  nurses, 
of  the  Municipal  Tuberculosis  Sanitarium  affording  limited  and  special 
nursing  care  which,  depending  upon  the  organization,  is  entirely  free 
to  all  needing  care  as  with  municipal  institutions,  or  is  free  to  those  un- 
able to  pay  and  with  a  small  charge  to  all  others. 

Of  the  1,909  families  reporting  in  full  in  regard  to  medical  care, 
only  91,  or  4.8  per  cent,  paid  for  nursing  serWce  during  the  year.  A 
somewhat  larger  number,  122,  had  free  nursing  service.     At  least  1,696, 

6  The  families  with  free  service  are  from  the  total  number  (2,005)  with  sick- 
ness; the  families  with  paid  service  are  from  a  smaller  total  (1,909)  of  those 
reporting   sickness   costs   in   full   and   in   detail. 


214 

or  88.8  per  cent  of  the  1,909  families  with  sickness  of  a  week  or  longer, 
were  without  the  care  of  a  nurse  in  the  home,  either  paid  or  free;  and 
only  198  families  had  hospitalized  cases.  While  nursing  service  would 
not  be  required  in  all  cases,  the  number  in  which  it  would  be  desirable  is 
obviously  far  greater  than  the  number  of  families  securing  it. 

Hospital  care. — It  is  not  wise  to  estimate  the  proportion  of  cases 
of  disabling  sickness  which  should  be  hospitalized.  Only  198  families, 
or  10.4  per  cent,  had  paid  for  and  only  201  families  had  free  hospital 
care  for  one  or  more  of  its  ill  members.  Few  will  question  that  it  would 
have  been  to  the  advantage  of  a  number  of  the  remaining  1,510,  or  79.1 
per  cent,  of  the  1,909  families  with  disabling  sickness,  to  have  had  the 
benefit  of  hospital  treatment  during  the  last  year. 

Dispensary  service. — Dispensary!  service,  of  general  and  special 
types,  is  offered  by  many  institutions.  The  dispensaries  of  the  Munici- 
pal Tuberculosis  Sanitarium  make  no  charge  for  treatment.  The  other 
dispensaries,  with  few  exceptions,  limit  their  services  to  the  poor.  More- 
over, where  the  family  is  financially  able,  they  often  require  the  pay- 
ment of  a  small  admission  fee,  and'  almost  always  require  payment  to 
cover  the  cost  of  materials  or  medicines  used.  A  separate  investigation 
w^as  made  of  dispensary  cases  in  the  Family  Study  and  appears  else- 
where as  Special  Report  III.  It  may  be  noted  here,  however,  that  143 
families,  or  7.5  per  cent,  report  payment  (usually  a  nominal  fee)  for 
dispensary  treatment,  and  22 G  families  report  free  service  at  dispensaries. 
At  least  1,540  families,  or  80.7  per  cent,  sent  no  members  to  dis- 
pensaries for  treatment. 

Medicine. — In  part,  outlay  for  medicine  represents  self -medication. 
Fifteen-hundred-thirty-three  or  80.3  per  cent  of  1,909  families  reporting 
sickness  costs  in  full,  had  outlays  for  medicine  during  the  yeaT.  This 
is  195  families  more  than  those  securing  the  paid  attendance  of  phy- 
sicians. Making  allowance  on  the  one  hand  for  the  families  where 
medicine  was  secured  free  or  its  cost  was  included  in  the  bill  of  the 
physician,  (as  is  often  the  case),  and  on  the  other  to  the  services  of  free 
physicians  and  of  the  dispensaries  we  may  conclude  that  a  considerable 
proportion  of  families  resorted  exclusively  (during  the  year)  to  self- 
medication.  It  is  not  necessary  to  point  out  the  serious  peril  that  may 
often  be  involved  in  the  use  of  patent  medicines  or  of  prescriptions 
based  upon  the  necessarily  faulty  diagnosis  of  laymen. 

This  statistical  survey  of  medical  service  among  block  families  re- 
veals partial  and  inadequate  use  of  existing  facilities.  What  is  the  ex- 
planation? Does  it  lie  in  economic  inability  to  secure  the  appropriate 
medical  service?  Is  it  the  lack  of  medical  service?  Is  it  the  absence 
of  adequate  medical  provision  by  the  community?  Is  it  the  mani- 
festation of  habits  of  mind  and  social  attitudes  peculiar  to  the  group 
studied?  The  comparative  study  of  nursing  service  and  of  charity  fami- 
lies may  throw  light  upon  these  questions. 

(4)  Protection  Against  Bisls  of  Sickness  and  Death. 

Many  Chicago  families  in  wage-earning  residence  areas  are  now 
protected  to  a  greater  or  less  degree  against  the  risks  of  sickness,  of 


215 

accident  and  of  death.  Data  bearing  upon  the  extent  of  this  protection 
by  insurance  or  otherwise,  and  the  amount  of  sickness,  accident  or  death 
benefit  received  were  secured  from  •  the  families  visited  in  the  block 
study. 

The  information  obtained  in  regard  to  disability  insurance  was, 
probably,  net  as  definite,  or  as  accurate  as  that  for  life  insurance.  The 
housewife  was  usually  the  informant  and  did  not  always  know  posi- 
tively whether  or  not  the  husband  had  health  and  accident  insurance, 
particularly  when  it  was  presumably  provided  by  an  establishment  fund. 

Cash  benefits  received  for  sickness  and  accident  during  the  year 
v.'ere  readily  remembered  and  accurately  reported  to  the  visitor.  The 
data  on  life  insurance  of  all  types  entered  upon  the  schedules  are  usually 
complete  and  correct  because  of  the  practice  of  the  agents  for  the  Com- 
mission of  consulting  the  policies  held  by  members  of  the  family.  More- 
over, as  already  indicated,  they  have  been  checked  by  competent  in- 
surance men. 

Health  and  accident  insurance. — Data  on  disability  insurance  for 
rhe  families  in  the  block  study  cover  the  following  points :  number  of 
persons  insured  classified  by  nationality  and  industrial  status,  number 
of  main  bread-winners  grouped  by  economic  status,  the  kinds  of  disability 
insurance  and  disability  benefits  received. 

Insurance  against  sickness  or  against  sickness  and  accident  is  con- 
fined, with  practically  no  exception,  to  persons  over  14  years  of  age. 
Accordingly,  Table  13  shows  the  disability  insurance  carried  by  persons 
over  14  years  of  age  classified  by  nationality  and  by  industrial  status  as 
gainfully  or  non-gainfully  occupied.  In  the  blocks  there  are  7,780 
persons  over  14  years  of  age.  Of  these  4,801  are  reported  as  gainfully 
occupied  and  2,979  as  non-gainfully  .occupied.  Of  the  4,801  gainfully 
occupied,  4,456  are  wage-earners  and  345  are  working  on  their  own 
account.  Of  the  4,456  wage-earners,  1,055,  or  23.7  per  cent,  were  re- 
ported as  carrying  disability  insurance;  of  the  345  working  on  their  own 
account  8^,  or  25.8  per  cent,  were  protected  by  insurance  against 
sickness  or  against  sickness  and  accident.  Of  the  2,979  non-gainfully 
occupied,  only  262  or  8,8  per  cent  were  returned  as  having  disability 
insurance. 

A  comparison  by  industrial  status  of  the  average  number  of  policies 
carried  per  person  insured  and  of  the  weekly  amount  of  disability  benefit 
provided  in  the  policy  is  of  interest.  Of  the  89  persons  working  on 
their  own  account  and  with  disability  insurance,  85  report  123  policies 
(or  membership  rights)  or  an  average  of  1.45  policies;  of  the  1,055 
wage-earners  insured,  978  report  1,126  policies  or  an  average  of  1.15 
policies;-  of  the  262  non-gainfully  occupied  insured,  245  report  272 
policies  or  an  average  of  1.11  policies. 

More  significant  is  the  average  amount  of  weekly  benefit  and  the 
number  insured  for  different  weekly  amounts  by  industrial  status  as 
indicated  in  the  following  table. 


216 


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218 


Number 

reporting 

in 

full. 

• 

Amount 

of 
weekly 
benefit. 

Average 
weekly- 
benefit 

per 

person 

insured. 

Per  cent  insured  for  respective 
sums  per  week. 

Industrial  status. 

Less  than 

$5. 

$5  to 

$9. 

$10  to 
$14. 

$15  and 
over. 

Working   on   own   ac- 
count   

85 
978 
245 

629 
6,643 
1,046 

7.40 
6.79 
4.68 

12.9 
10.9 
45.7 

72.9 
70.3 

48.2 

9.4 

14.1 

4.9 

4.7 

Wage  earner 

4.6 

Non-gainfully  occupied 

1.2 

These  data  relating  to  the  proportion  of  persons  insured^  the  average 
number  of  policies,  the  average  weekly  benefits,  and  the  distribution  by 
amounts  of  benefit  indicate : 

(1)  That  nearly  three-fourths  of  those  working  on  their  own 
account,  and  over  three-fourths  of  the  wage-earners  do  not  report  them- 
selves as  protected  against  the  risk  of  sickness. 

(2)  That  over  nine-tenths  of  the  non-gainfully  occupied  over  four-  • 
teen  years  of   age   are  reported   as   unprotected  by   insurance  against 
sickness. 

(3)  That  the  insured  among  the  persons  occupied'  on  their  own 
account  are  somewhat  more  favorably  situated  in  the  average  number 
of  policies,  the  average  weekly  benefits,  and  in  the  distribution  by  the  . 
amount  of  benefits  than  are  the  wage-earners. 

Variations  by  nationality  in  the  proportion  insured  indicate  that 
differences  in  customs  and  habits  of  the  various  immigrant  groups  in 
Chicago  affect  decisively  the  number  of  persons  insured.  The  per- 
centage of  those  insured  against  sickness  among  the  4,456  wage-earners 
is,  as  has  been  stated,  23.7  per  cent;  the  proportion  among  the  national 
and  racial  groups  is  highest  with  the  Lithuanian  (51.4  per  cent),  fol- 
lowed by  United  States  Colored  (44.3  per  cent),  Scandinavian  (28.9 
per  cent), Pole  (27.9  per  cent),  Bohemian  (25.7  per  cent),  "Other 
Nationalities"  (23.0  per  cent),  Jew  (20.6  per  cent),  Itcilian  (18.5  per 
cent),  German  (14.4  per  cent),  United  States  White  (13.9  per  cent), 
Irish  (5.8  per  cent).  The  distribution  by  nationality  of  non-wage- 
earners  insured  is  not  markedly  different  from  that  indicated  for  wage- 
earners.  In  the  group  of  the  non-gainfully  occupied  the  most  evident 
differences  by  nationality  are  the  small  proportion  of  United  States 
White  insured  (2.6  per  cent)  and  the  still  smaller  proportions  among  the 
Jews  (0.8  per  cent),  and  the  Irish  (0.6  per  cent). 

Quite  complete  information  was  obtained  in  regard  to  benefit  re- 
ceived from  sickness  insurance  carriers.  Table  14  shows  a  comparison 
of  the  disability  benefits  paid  with  number  of  wage-earners  sick,  number 
losing  wages,  and  the  total  amount  of  wages  reported  as  lost.  The  total 
number  of  wage-earners,  4,474  includes  18  persons  14  years  of  age  or  less 
and  is  therefore  larger  than  the  number  of  wage-earners  over  14  years 
as  given  in  Table  13.  Of  the  4,474  wage-earners,  1,222  were  sick,  of 
this  latter  number  937  lost  at  least  one  week's  wages  and  126  received 
sickness  benefits  from  133  different  carriers.  The  source  of  practically 
one-half  (6G)  of  the  disability  payments  received  is  found  in  fraternal 


219 


TABLE  14— SICKNESS  OF  WAGE-EARNERS,  LOST  WAGES  AND  DISABILITY 
BENEFITS   RECEIVED,   BY  ECONOMIC   STATUS. 


1 

=8 

o 

t-l 

© 

^  >-> 

o  ® 
Eh 

M 

o 

i-i 

a 

Number  losing  wages 
for  more  than  one 
week. 

Wages  lost. 

^  9. 

a  « 

Benefits 
received. 

♦Number  of  sources  of 
benefits  received. 

Economic  status. 

d  t,  03 

4.^ 

a 
< 

c 
^  o 

4-» 
O 

a 

a 

•6 

'  B 

t^a 

o 

..-4 

'a 

?  ^ 
is  » 

^  . 

©  a 

§a 

1— t 

Block  study 

4,474 

1,222 

937 

906 

$107,595 

126 

125 

$6,555 

30 

14 

8 

66 

15 

Class  A ; 

2,770 
937 
373 
215 
160 
19 

409 

746 

273 

139 

36 

27 

1 

143 

563 

223 

108 

27 

16 

555 

218 

105 

15 

13 

66,241 

22, 223 

14, 872 

1,708 

2,551 

89 

27 

8 

2 

89 

27 

8 

1 

5,037 

1,187 

176 

155 

25 
3 
1 
1 

11 
3 

7 

1 

39 

20 

6 

1 

1? 

Class  B 

?. 

Class  C 

1 

Class  D 

Class  0  

Class  R 

Nursing  service  study. . . 

116 

115 

12,213 

7 

7 

313 

3 

1 

.... 

3 

.... 

Class  A 

202 

130 

64 

8 

3 

2 

878 

76 

41 

20 

4 

2 

65 

31 

16 

3 

1 

65 

31 

16 

2 

1 

$    7,645 

2,648 

1,738 

152 

30 

5 

1 
1 

5 

1 
1 

$    196 

99 
18 

1 
1 
1 

1 

3 

Class  B 

Class  C 

Class  D 

Class  0 

Class  R     . 

Charity  study 

602 

494 

456 

105,438 

54 

51 

2,834 



8 

13 

29 

9 

*  Total  number  of  sources  greater  than  number  of  persons  receiving  sick 
benefits,  because  in  a  number  of  cases  one  person  received  benefits  from  two  or  more 
sources. 


220 

orders.     The  other  sources  of  payment  on  account  of  disability  are  em- 
ployer, 30;  commercial  carriers,  15;  establishment  funds,  14;  unions,  8. 
Certain  significant  points  are  revealed  in  the  following  table  which 
is  based  on  the  data  in  Table  14. 


Number 

Per 

Number 

losing 

cent 

Number 

Per  cent 

Average 

Average 

Actual  economic 

of 

wages 

wage 

paid 

of  sick 

wage 

benefit 

status. 

wage 

for  more 

earners 

sick 

paid 

loss  per 

re- 

earners 

than  one 
week. 

losing 
wages. 

benefits 

benefits 

man 

ceived 

Per  cent 
of  bene- 
fit of 
wage  loss. 


A 

2,770 
937 
375 

4,474 

563 
223 
108 
937 

24.8 
23.8 
29.0 
20.9 

89 

27 

8 

126 

15.8 

12.1 

7.4 

13.4 

$119.  35 
101.  93 
141.  64 
118.  76 

$56.60 
43.96 
22.00 
52.44 

47.4 

B 

43.1 

C 

15,5 

♦AH 

44.1 

•  Includes  392   wage-earners  in  addition  to  those   classed   "A,"    "B,"   and  "C." 

Important  conclusions  to  be  derived  from  a  study  of  this  table  are : 

(1)  That  while  20.9  per  cent  of  the  4,474  wage-earners  lost  wages 
for  one  week  or  more  during  last  year,  only  13.4  per  cent  of  these  received 
sick  benefits. 

(2)  That  the  average  loss  of  wages  was  $118.76  and  that  the 
average  benefit  received  was  $52.44,  or  44.1  per  cent  of  the  amount  lost 
by  the  insured  wage-earners. 

(3)  That,  taking  the  group  as  a  whole,  the  disability  insurance 
received  was  5.9  per  cent  of  wages  lost  because  of  sickness  or  accident 
disabling  for  more  than  a  week. 

(4)  That  not  only  was  the  proportion  of  sickness  greater  (29.0  per 
cent)  in  Class  C  (the  poverty  group)  than  in  Class  B  with  meager  in- 
comes (23.8  per  cent),  and  in  Class  A  with  higher  incomes  (24.8  per 
cent),  but  also  the  largest  average  loss  of  wages  was  $141.64  for  Class 
C  as  compared  with  $101.93  for  Class  B  and  $119.35  for  Class  A. 

(5)  That  the  average  benefit  was  markedly  smaller  with  wage- 
earners  in  Class  C  ($22)  than  with  Class  B  ($43.96)  and  Class  A 
($56.60),  and  that  per  cent  of  benefit  to  wages  lost  was  much  lower  in 
Class  C  (15.5  per  cent)  than  in  Class  B  (43.1  per  cent)  and  in  Class  A 
(47.4  per  cent). 

Because  of  the  acute  economic  strain  usually  resulting  from  the 
sickness  of  the  main  breadwinner  in  the  family,  a  separate  analysis  was 
made  for  husbands  gainfully  occupied.  The  data  indicating  number 
insured,  number  of  policies,  and  amount  of  weekly  benefit  provided  are 
presented  in  Table  15.  Of  2,542  husbands  gainfully  occupied,  925, 
or  36.4  per  cent,  have  disability  insurance.  The  proportion  with  pro- 
tection against  sickness  is  somewhat  higher  with  wage-earning  husbands 
(those  in  Classes  A,  B,  C,  and  D,  36.7  per  cent)  than  with  husbands 
working  on  their  own  account  (Class  0,  33.3  per  cent).     The  follow- 


2-21 


TABLE    15— DISABILITY    INSURANCE    OF    HUSBANDS    GAINFULLY    OCCU- 
PIED,  BY  ECONOMIC   STATUS. 


Economic  status  of  the 

Total 
number 
of  hus- 
bands. 

Num- 
ber in- 
sured. 

Num- 
ber re- 
porting 
in  full. 

Num- 
ber of 
policies. 

Total 
benefit 

per 
week. 

Number  of  persons  with  specified 
number  of  policies. 

family. 

1 

2 

3 

4  and 
over. 

Block  study 

2,542 

925 

858 

1,024 

$6,065 

737 

100 

17 

4 

Class  A 

1,475 

559 

215 

66 

227 

271 

565 

219 

52 

14 

75 

67 

517 
212 

50 
9 

70 

58 

615 

241 

52 

9 

107 

67 

$3,812 

1,369 

279 

42 

563 

497 

436 
185 

48 
9 

59 

50 

66 

25 

2 

14 
2 

1 

Class  B 

Class  C 

Class  D 

Class  0  

7 
7 

1 
1 

3 

Nursing  service  study 

Class  A  

122 

83 
43 

33 

20 

9 

30 

15 

9 

35 
16 
10 

$297 
98 
63 

25 
14 

8 

5 
1 

1 

Class  B 

Class  C 

Class  D . 

Class  0  

23 
421 

5 

84 

4 
69 

6 
70 

39 
409 

3 

68 

1 

i 

Charitv  studv 

222 


mg  table  brings  out  significant  facts  in  regard  to  the  disability  insurance 
carried  by  2,315  wage-earning  husbands. 


Economic  status  of  wage-earning 
husbands. 

Number. 

Number 
insured. 

Per  cent 
insured. 

Number 
reporting 
amount  of 
insurance. 

Average 
amount  of 
insurance 

per  week. 

A 

1, 475 
559 
215 

2,315 

565 

219 

52 

850 

38.3 
39.2 
24.2 
36.7 

517 

212 

50 

788 

-                 t 

$7. 37 

B 

6.46 

C 

5.58 

All* 

6.98 

*  Includes   66   husbands   not  classed  as   "A,"   "B,"   or  "C." 

The  chief  conclusions  to  be  derived  from  a  study  of  this  table  are : 

(1)  That  while  the  proportion  of  wage-earning  husbands  insured 
is  54.9  per  cent  higher  than  that  of  all  wage-earners  (23.7  per  cent  as 
shown  above),  only  36.7  per  cent  or  not  quite  three  in  eight  have  health 
insurance. 

(2)  That  the  heads  of  families  in  Class  C  (the  poverty  group) 
where  loss  of  w^ages  is  followed  by  the  greatest  deprivation,  are  least 
frequently  insured. 

(3)  That  the  average  amount  of  insurance  received  per  week  in 
case  of  sickness  is  considerably  smaller  for  Class  C  ($5.58)  than  for 
Classes  B  and  A  ($6.46  and  $7.37  respectively). 

By  reference  to  Table  15  it  is  found  that  the  difference  by  economic 
status  in  average  amount  of  weekly  benefit  carried  is  explained  for  the 
most  part  by  the  larger  proportion  of  heads  of  families  with  two  or  more 
policies  in  Classes  A  and  B  than  in  Class  C.  At  all  events,  the  dis- 
advantageous situation  of  heads  of  families  in  Class  C  is  apparent. 

Life  insurance. — As  shown  by  Table  16,  more  than  four  families 
in  five  in  the  Block  Study  (2,496  out  of  3,048)  had  one  or  more  of  their 
members  protected  by  some  form  of  life  insurance.  Of  the  12,450 
members  in  these  families  7,193  or  57.8  per  cent  were  policyholders. 
The  total  number  of  policies  in  force  was  7,721  and  the  average  benefit 
provided  by  the  policies  (on  the  basis  of  the  amounts  reported  for  7,194 
policies)  was  $419.24. 

Noteworthy  differences  in  protection  against  the  risk  of  death,  both 
in  proportion  of  families  with  insurance  and  in  the  average  amount  of 
death  or  funeral  benefit,  appear  by  nationality  and  by  economic  status. 
In  the  order  of  rank  by  percentage  of  families  with  insurance  the  United 
States  Colored  lead  (93.8  per  cent),  followed  by  Bohemian  (88.9  per 
cent),  Polish  (88.5  per  cent),  Irish  (88.4  per  cent),  United  States 
White  (85.2  per  cent),  German  (85.0  per  cent),  Lithuanian  (79.5  per 
cent),  Scandinavian  (75.4  per  cent),  "Other  Nationalities"  (75.1  per 
cent),  Jewish  (63.8  per  cent),  Italian  (57.8  per  cent).  Over  against 
the  proportion  of  families  with  insurance  it  is  interesting' to  note  the 
variations  in*  average  amount  of  the  policy  according  to  the  nationality 
of  the  head  of  the  family.  In  po  far  as  protection  against  the  risk  o? 
death  is  to  be  gauged  by  the  amount  of  death  benefit,  the  best  protected 
families  are  the  Bohemian  ($577.58),  followed  by  United  States  White 


223 


TABLE     16— LIFE    INSURANCE    OF    ALL    KINDS    FOR    FAMILIES    IN    THE 
BLOCK  STUDY,  BY  NATIONALITY  AND  ECONOMIC   STATUS. 


Nativity  or  race  of  head 
family. 


of 


c 


"3  a 


03 
O 


cS 


s 

S.2 


<D 

Pi 


©     . 

ES 
o  o 


<s 

§  =  s 

E  ^S 


O  fc- 

2>. 


C3 
O 


o 
t-l 

a 


c3  o 


o    . 

O  C3 


3 
o 

C3 
'cfl 
O 

Eh 


c3  +;> 


>  o 


All  families 

United  States,  white. 
United  States,  colored 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian 

Other. 

Economic  status — 

All  families 

Class  A 

Class  B  

ClassC 

Class  D  

Class  O 

Class  R  


3,048'  2,496 


644 
274 
243 
240 
129 
204 
218 
117 
522 
232 
225 


3,048 


1,687 
631 
280 
110 
267 
73 


549 
257 
216 
204 
114 
118 
139 
93 
462 
175 
169 


2,496 


1,425 
537 
205 

88 
200 

41 


81.9 


85.2 
93.8 
88.9 
85.0 
88.4 
57.8 
63.8 
79.5 
88.5 


12,450 


75.4 
75.1 


2,385 
854 
942 
917 
601 

1,017 

1,116 
488 

2,434 
798 
898 


81.9112,450 


84.5 
85.1 
73.2 
80.0 
74.9 
56.2 


6,090 
3,084 
1,519 

466 
1,122 

169 


10,421 


2,066 
798 
860 
812 
549 
627 
730 
396 

2,254 
633 
696 


10,421 


5,281 

■2,667 

1,114 

379 


94 


7,193  7,721 


1,565 
710 
596 
596 
463 
306 
259 
249 

1,581 
419 
449 


7,193 


3,700 

1,853 

770 

281 

507 

82 


1,685 
789 
616 
635 
484 
311 
274 
327 

1,647 
490 
463 


7,721 


i,005 

1,948 

803 

302 

577 

86 


7,194 


1,599 
701 
594 
588 
462 
283 
270 
246 

1,572 
448 
431 


7,194 


$3,016,032 


$856,355 
141,237 
343,082 
244,895 
235,953 
114,316 
125,574 
41,914 
555, 674 
179,910 
177, 122 


3,016,032 


3,746!$1,750,647 


1,834 
758 
250 

528 
78 


585,262 
218,866 
115,929 
311,031 
34,297 


$419.  24 


$535.56 
201.48 
577. 58 
416.  49 
510. 72 
403. 94 
465.09 
170. 38 
353.48 
401. 58 
410.96 


419.  24 


$467. 34 
319. 12 
288.74 
463. 72 
589.07 
439.71 


QO 


24 


TABLE  17 — DISTRIBUTION  OF  LIFE  INSURANCE  OF  FAMILIES  AMONG  MEM 

NOMIC 


Nativity  or  race  of  head 
of  family. 


tn 

.2 

Husbands. 

n3 

E 

^ 

s 

.2  3 

o 

'2 

o 

2  S 

be 

B 

3 

o 

■#-■ 

o 

of  po 
ngam 

e 

ii 

1-1 

■M 

b. 

(-•^ 

2 

© 

c 

© 

sti 

ja 

,Q 

s> 

x> 

X5  O 

"3 

a 

a 

o 

a 

M    03 

o 

3 

3 

o 

3 

3  £ 

H 

;z; 

^ 

Pi 

Z 

Z 

3 
3 


Wives. 

i 

.2^ 

•o 

•3 

of  polic 
ng  amou 

2 

3 

.3 

O 

bl 

bi 

•tj 

ll 

u."3 

© 

© 

c 

© 

©1- 

ja 

.Q 

© 

X5 

X5  O 

a 

a 

© 
© 

a 

3 

3 

3 

3  £ 

;z; 

iz; 

^ 

Z 

Z 

3 
d 


All  families 

U.  S.,  white... 
U.S.,  colored . 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian., 
Other 

Economic  status- 
All  families 

Class  A 

Class  B.... 
Class  C... 
Class  D . . . 
Class  O . . . 
Class  R . . . 


12,450 

2,640 

1,974 

74.8 

2,325 

2,045 

2,385 

559 

455 

81.4 

539 

485 

854 

211 

185 

87.7 

208 

179 

942 

200 

163 

81.5 

172 

165 

917 

194 

147 

75.8 

176 

155 

601 

92 

79 

85.9 

96 

92 

1,017 

1-96 

91 

46.4 

93 

72 

1,116 

200 

124 

62.0 

138 

134 

488 

111 

75 

67.6 

144 

93 

2,434 

497 

392 

78.9 

438 

389 

798 

178 

128 

71.9 

176 

152 

898 

202 

135 

66.8 

145 

129 

12,450 

2,640 

1,974 

74.8 

2,325 

2,045 

6,090 

1,497 

1,162 

77.6 

1,374 

1,218 

3,084 

568 

427 

75.2 

486 

425 

1,519 

227 

149 

65.6 

162 

145 

466 

86 

65 

75.6 

75 

56 

1,122 

234 

155 

66.2 

210 

187 

169 

28 

16 

57.1 

18 

14 

11,551,017 


$504, 164 

52,363 

142, 138 

120,101 

101,390 

66, 613 

84,436 

16, 108 

256, 125 

108,691 

98,888 


2,942 


624 
266 
232 
226 
119 
201 
215 
115 
514 
212 
218 


1,551,017  2,942 


$943,243 

283,532 

99,047 

44,057 

170,938 

10,200 


1,620 
625 
276 
101 
255 
65 


1,729!  58. 8 


390!62.  5 

231  86.8 

174|75.0 

143  63.3 

99  83.2 

4723.4 

55  25.6 

60  52.2 

335:65. 2 

94  44.3 


101 


1,729 


46.3 


58.8 


959  59.2 

397  63.5 

153  55.4 

58  57.  4 


131 
31 


51.4 
47.7 


1,823 


414 

254 

182 

147 

100 

48 

55 

69 

351 

102 

101 


1,675 


385 

224 

177 

141 

93 

41 

55 

40 

333 

95 

91 


1,823' 1,675 


1,010 
417 
157 

65 
142 

32 


940 
381 
142 

52 
131 

29 


$793,362 


$187,505 
47,312 

131,958 
56, 165 
65,896 
25,686 
25, 108 
13,344 

170,516 
29,377 
40, 495 


793,362 


$437,113 
170,334 
59,689 
30,850 
79,021 
16,355 


225 


BERS   OF  FAMILIES   IN  THE   BLOCK  STUDY,   BY   NATIONALITY   AND    ECO- 
STATUS. 


Unmarried  males  over  14. 

Unmarried  females  over  14. 

Children  14  an( 

i  under. 

i 

to  ^ 

.2  3 

• 

i 

.2^ 

■ 

i 

"4  H 

• 

• 

•-! 

o  3 

u 

• 

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Ui 

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V 

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S  o 

3 

"?> 

=§ 

a 

■A  b 

3 

V. 

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3 
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— ^ 

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3 
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3 

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(_ 

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ii 

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u, 

u'-3 

-«-> 

u< 

u 

♦J 

u> 

ui-rS 

•tj 

o 

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fl 

<D 

®ti 

G     • 

© 

<s> 

^ 

© 

®T^ 

^        • 

« 

« 

3 

© 

<»t2 

3    • 

XI 

Xi 

<a 

£i 

.o  O 

3  ?" 

^ 

JO 

o 

ja 

J2  O 

3  9, 

X5 

-Q 

<S 

XI 

XJ  o 

3  S 

^^ 

B 

o 

S 

sg- 

0)i 

S 

s 

o 

S 

B% 

o  5i 

s 

a 

« 

a 

a& 

la 

3 

3 

a> 

3 

3  2 

S  OS 

3 

3 

a> 

3 

3  2 

3 

3 

<D 

3 

3  2 

a  08 

Z 

'Z, 

Ph 

z, 

Z; 

< 

;^  ,  2 

Pm 

'Z. 

z 

<5 

^ 

:z; 

pL. 

iz; 

;z; 

<i 

1,086 

614 

56.5 

643 

612 

$258,925 

1,112 

596 

53.6 

627 

600 

$184,278 

4,670 

2,280  48.8 

2,303 

2,262|$228,450 

190 

111 

58.4 

117 

116$  68,837 

213 

132 

62.0 

138 

138 

43,957 

799 

477  59. 7 

477 

475'$  51,892 

74 

58 

78.4 

64 

57 

12,284 

95 

65 

68.4 

78 

72 

11,917 

208 

171  82.  2 

185 

169 

17,361 

106 

62 

58.5 

62 

57 

27,972 

102 

56 

54.9 

59 

56 

26,233 

302 

141  46.  7 

141 

139 

14,781 

128 

87 

68.0 

90 

86 

32,798 

122 

76 

62.3 

77 

71 

20,543 

247 

143  57.  9 

145 

135 

15,288 

80 

63 

78.8 

66 

63 

24,689 

95 

76 

80.0 

76 

73 

28,843 

215 

146  67. 9 

146 

141 

15,135 

So 

16 

18.8 

17 

17 

5,453 

67 

24 

32.7 

25 

25 

6,085 

468 

128  27. 4 

128 

128 

10,479 

94 

17 

18.1 

18 

18 

10,820 

106 

4 

3.8 

4 

4 

540 

501 

59 

11.8 

59 

59 

4,670 

16 

10 

62.5 

10 

10 

2, 534 

12 

8 

66.7 

8 

7 

1,278 

234 

96 

41.0 

96 

96 

8,650 

159 

101 

63.5 

101 

98 

33, 501 

133 

87 

65.4 

90 

90 

29,123 

1,131 

666 

58.9 

667 

662 

66,409 

88 

57 

64.8 

64 

59 

24,114 

98 

37 

37.8 

39 

33 

7,662 

222 

103 

46.4 

109 

109 

10,066 

66 

32 

48.5 

34 

31 

15,923 

69 

31 

44.9 

33 

31 

8,097 

343 

150 

43.7 

150 

149 

13,719 

1,086 

614 

56.5 

643 

612 

258,925 

1,112 

596 

53.6 

627 

600 

184,278 

4,670 

2,280 

48.8 

2,303 

2,262 

228,450 

643 

403 

62.7 

424 

415 

$175,747 

594 

350 

58.9 

365 

351 

$114,220 

1,736 

826 

47.6 

832 

822 

$80,324 

166 

85 

51.2 

90 

89 

25,841 

213 

107 

50.2 

112 

110 

24,385 

1,512 

837 

55.4 

843 

829 

81,170 

71 

27 

38.0 

27 

27 

10, 182 

83 

44 

53.0 

51 

51 

10,153 

862 

397 

46.1 

406 

393 

39,795 

64 

38 

59.* 

38 

29 

14,542 

77 

46  59.  7 

48 

4Q 

18, 172 

138 

74 

53.6 

76 

73 

8,308 

130 

54 

41.5 

57 

46 

29,180 

129 

42 

32.6 

43 

40 

15,253 

374 

125 

33.4 

125 

124 

16,639 

12 

7 

58.3 

7 

6 

3,433 

16 

7 

41.3 

8 

8 

2,095 

48 

21 

43.8 

21 

21 

2,214 

-15  H  I 


226 


i 


($535.56),  Irish  ($510.72),  Jew  ($465.09),  German  ($416.49),  "Other 
Nationality"  ($410.96),  Italian  ($403.94),  Scandinavian  ($401.58), 
Pole  ($353.48),  United  States  Colored  ($201.48),  Lithuanian  ($170.38), 
The  group  of  United  States  Colored  with  the  largest  proportion  of 
families  with  insurance  against  death  had  next  to  the  lowest  average 
amount  of  insurance  or  funeral  benefit. 

The  variations  in  the  relative  number  of  wage-earning  families 
with  insurance  and  in  the  average  value  of  the  policy  indicate  the  un- 
favorable situation  of  the  "poor'^  families  (those  in  Class  C)  in  the 
blocks  studied.  Of  the  families  with  moderate  and  meager  incomes  a 
somewhat  larger  proportion  are  insured  (Class  A,  84.5  per  cent  and 
Class  B,  85.1  per  cent)  than  of  Class  C  families  with  deficient  incomes 
(73.2  per  cent).  In  these  same  three  classes,  taking  the  total  members 
in  the  families,  60.8  per  cent  of  those  in  Class  A,  60.1  per  cent  in  Class 
B,  and  50.7  per  cent  in  Class  C  are  insured.  The  average  number  of 
policies  per  policy  holder  in  Class  A  is  1.08,  in  Class  B  1.05,  and  in 
Class  C  1.04.  The  differences  in  the  amount  of  protection  provided  by 
the  policies  also  show  the  far  more  advantageous  position  of  families 
outside  the  poverty  group  (average  value  of  policy  $467.34  with  Class 
A,  $319.12  with  Class  B)  as  compared  with  the  poor  (average  value  of 
policy  $288.74  with  Class  C).  The  figures  for  the  average  amounts  of 
insurance  per  policyholder,  which  still  further  accentuate  the  unfavor- 
able situation  of  "poor"  families,  are  about  $505  in  Class  A,  $335  in 
Class  B,  and  $300  in  Class  C.  The  proportion  of  families  in  Class  0 
(those  working  on  their  own  account)  with  insurance  is  somewhat 
lower  than  for  wage-earning  families  (74.9  per  cent  of  families  on  own 
account  as  against  83.3  per  cent  of  wage-earning  families),  but  the 
average  value  of  the  policy  is  considerably  higher  than  that  of  wage- 
earning  families  ($589.07  as  against  $467.34  in  Class  A— the  group 
of  wage-earning  families  better  off  economically.) 

The  distribution  of  life  insurance  among  the  different  members 
of  the  families,  as  given  in  Table  17,  shows  significant  divergencies.  Of 
the  12,450  persons  in  all  the  families  in  41  blocks,  7,193,  or  57.8  per 
cent,  were  insured  for  various  amounts.  Of  husbands,  74.8  per  cent 
were  insured;  of  wives,  58.8  per  cent;  of  males  over  14,  other  than 
husbands,  56.5  per  cent;  of  females  over  14,  other  than  wives,  53.6  per 
cent;  of  children  under  14,  48.8  per  cent.  The  average  values  of  policies 
for  the  five  gi'oups  in  the  order  just  mentioned  are  $758,  $474,  $423, 
$307,  and  $101. 

Interesting  differences  occur  in  the  distribution  of  insurance  among 
the  various  members  of  the  family  by  nationality  and  by  economic  status. 
With  the  United  States  White,  the  Colored,  the  Bohemian,  the  German, 
the  Irish  and  the  Polish  at  least  one-half  of  the  persons  in  the  different 
age  and  sex  groups  have  life  insurance  policies.  Differences  ^re  pro- 
nounced among  the  Italians  who  as  a  group  are  under-insured,  where 
less  than  one  in  four  wives,  less  than  one  in  five  unmarried  males  over 
14,  and  more  than  one  in  four  children  fourteen  and  under  are  insured. 
With  the  Jews  the  divergencies  are  greatest.  Although  three  in  ten 
hufibajids  are  insured,  only  one  in  four  wives,  one  in  five  unmarried 


i 


227 

male  adults^  one  in  twenty-five  unmarried  female  adults,  and  one  in  eight 
of  children  14  years  of  age  and  under  are  insured.  Quite  clearly  social 
attitudes  of  nativity  groups  influence  the  distribution  of  insurance  over 
the  members  of  the  family. 

Variations  by  economic  status  in  proportion  insured  in  the  sex  and 
age  groups  show  certain  unexpected  results.  Members  of  families  in 
Class  C  with  deficient  incomes  in  all  but  one  case  (unmarried  females 
over  14)  have  a  smaller  proportion  insured  than  families  in  Class  B  with 
meager  incomes ;  and  in  all  cases,  have  a  smaller  proportion  insured  than 
the  "better  off"  families  in  Class  A.  The  difference,  however,  is  incon- 
siderable in  the  case  of  wives  (Class  A,  59.2  per  cent;  Class  B,  63.5  per 
cent;  Class  C,  55.4  per  cent),  and  unmarried  females  over  14  (Class  A, 
58.9  per  cent;  Class  B,  50.2  per  cent;  Class  C,  53.0  per  cent).  The 
difference  is  considerable  in  the  case  of  wage-earning  husbands  (Class 
A,  77.6  per  cent;  Class  B,  75.2  per  cent;  Class  C,  65.6  per  cent),  and  is 
particularly  marked  with  unmarried  males  over  14 (Class  A,  62.7  per 
cent;  Class  B,  51.2  per  cent;  Class  C,  38.0  per  cent). 

Here  again  an  analysis  of  proportion  insured  and  amount  of  in- 
surance of  wage-earning  male  heads  is  of  interest.  Of  especial  interest 
is  the  life  insurance  carried  by  male  heads  of  families  in  the  Block  Study 
as  presented  in  Table  18.  Of  the  total  number  (2,756)  of  male  heads 
of  families,  2,652,  or  96.2  per  cent,  are  gainfully  occupied.  Of  the 
gainfully  occupied  male  heads  of  families,  2,002  or  76.2  per  cent  had 
2,380  life-insurance  policies.  The  relative  number  insured  according 
to  nativity  of  the  head  of  the  family  does  not  differ  signally  from  that  of 
number  of  families  (Table  16)  or  number  of  members  (Table  17)  in 
so  far  as  life  insurance  is  concerned  except  that  the  Irish  (with  88.4 
of  male  heads  insured)  displace  the  United  States  Colored  (with  85.5 
per  cent  of  male  heads  insured)  for  first  place. 

Of  a  total  of  2,417  wage-earners  (those  in  Classes  A,  B,  C,  D), 
1,865  or  77.2-per  cent  were  insured.  The  total  number  of  policies  carried 
was  2,167;  the  value  of  1,908  of  these  was  $1,396,673,  or  an  average  of 
$732  each.  In  other  words,  77.2  per  cent  of  the  wage-earning  male  heads 
of  families  were  insured  for  an  average  of  approximately  $850.  The  rela- 
tive number  of  male  heads  insured  in  Class  A  families  (those  "better 
off")  is  78.8  per  cent  for  an  average  of  approximately  $854;  in  Class  B 
families  (with  meager  incomes),  76.2  per  cent  for  an  average  of  $765; 
in  Class  C  families  (with  deficient  incomes),  68.4  per  cent  for  an 
average  of  $742. 

The  number  of  policies  and  amount  of  insurance  in  organizations 
of  various  kinds  has  been  tabulated  for  male  heads  of  wage-earning 
families  only.  The  number  of  "ordinary  life  policies"  reported  was 
206,  the  amount  $269,700;  of  "industrial  policies,"  578,  the  amount 
$286,205;  of  fraternal  policies  952,  the  amount  $743,819;  of  union 
membership  certificates  providing  death  benefits  or  insurance,  115,  the 
amount  $69,048;  of  other  policies  (in  foreign  benefit  societies,  etc.)  57, 
the  amount  $27,501.  Thus  almost  half  of  the  policies  reported  (952  of 
1,908)  and  more  than  half  of  the  insurance  ($743,819  of  $1,386,673) 
were  in  fraternal  orders.     This  is  not  true  of  other  members  of  these 


228 


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229 

families.  Nearly  all  of  the  insurance  of  children,  for  example,  is 
"industrial/^  The  average  value  of  insurance  policies  for  all  male 
heads  gainfully  occupied  where  the  amount  of  death  benefit  was  re- 
ported was  $732.  In  the  different  types  of  insurance  the  average  amount 
of  the  policv  was  naturally  highest  with  the  "ordinary  life"  ($1,352), 
followed  by"^  fraternal  ($769),  union  ($598),  industrial  ($526)  and 
other  \$4;:6). 

III.     THE  NURSING  SERVICE  STUDY. 

The  families  in  the  Nursing  Service  Study  are  a  selected  group. 
They  were  chosen  as  typical  of  cases  under  the  care  of  the  Visiting  Nurse 
Association.  They  are,  therefore,  not  representative  of  families  taken 
at  random  from  the  wage-earning  group  in  Chicago.  The  data  have 
value  because  they  tend  to  confirm  important  results  obtained  in  the 
Block  Study,  especially  as  to  the  relation  between  insurance  and  economic 
condition.  More  important,  they  have  a  bearing  on  medical  treatment 
and  service,  for  these  families  are  largely  an  American  group  while  in 
the  Block  Study  approximately  seven  in  ten  of  the  heads  of  families  were 
foreign-born. 

In  size  the  nursing  service  family  is,  on  the  average,  larger  than  the 
block  family.  The  age-grouping  reveals  a  higher  proportion  of  young 
children  and  of  persons  from  twenty  to  forty-four.  Relatively  few  of  the 
families  have  been  disrupted  by  death  or  desertion  of  the  usual  bread- 
winner. Another  characteristic  of  the  nursing  service  families  is,  as 
already  suggested,  the  small  proportion  with  parents  foreign-born.  They 
are,  in  general,  a  native-born  group.  The  characteristic  difference  in  eco- 
nomic status  between  the  nursing  service  and  the  block  families  is  that 
a  smaller  proportion  of  them  are  Class  A  families. 

The  data  secured  from  the  nursing  service  group,  as  in  the  case  of 
the  block  families,  will  be  analyzed  under  four  heads. 

(a)  Sickness  in  nursing  service  families. 

(b)  Individual  and  family  sickness  costs. 

(c)  Care  of  the  sick. 

(d)  Existing  protection  against  health  risks. 

(1)  SicJcness  in  Nursing  Service  Families. 

The  method  of  selecting  the  cases  is  responsible  for  the  fact  that  in 
297,  or  97.7  per  cent  of  the  304  families,  disabling  sickness,  usually  for 
a  week  or  more,  was  experienced.®  That  710,  or  45.8  -per  cent,  of  the 
1,550  persons  in  these  families  were  sick  as  com'pared  with  27.7  per  cent 
in  block  families  is  to  be  explained  in  the  same  way. 

(2)  Sichness  Costs. 

Of  the  710  persons  sick  in  the  nursing  service  families,  148  were 
wage-earners,  10  were  otherwise  gainfully  employed,  and  552  were  not 
gainfully  occupied.^  The  sickness  costs  of  the  555  (of  576  total  with 
costs)  returning  complete  reports  total  $35,600,  or  an  average  of  $64.1-1: 

«  See  Table  6,   p.   203,  for  detailed  comparison. 
^  -See  Table  7,  p.  206. 


230 


per  person  as  compared  with  an  average  of  $71.46  per  person  sick  in  the 
Block  Study.  This  difference  in  sickness  costs  is  in  direct  outlays  rather 
than  in  lost  wages  as  shown  by  the  fact  that  125  of  the  129  wage-earners 
with  sickness  costs  reported  an  average  of  $40.53  for  sickness  outlays 
and  $93.71  for  lost  wages.  The  comparative  per  capita  illness  loss  of 
wage-earners  in  block  families  was  $24.29  for  direct  outlays,  and  $101.04 
for  lost  wages.  For  the  non-gainfully  occupied  the  average  direct  sick- 
ness outlays  for  427  reporting  completely  (out  of  444  persons  with  sick- 
ness costs)  was  $18,785,  or  an  average  of  $43.99. 

.  Table  8^  shows  that  143,  or  35.0  per  cent,  of  the  wage-earners  in  the 
visiting  nurse  study  were  sick  in  the  course  of  the  year.  The  correspond- 
ing, but  not  comparable,  figure  in  the  block  study  was  27.3  per  cent. 

The  average  time  lost  from  work  by  the  block  wage-earner  was  7.3 
weeks;  by  the  nursing  service  wage-earner,  6.4  weeks,  a  difference  of 
almost  one  week.  The  percentage  loss  of  wage  on  the  basis  of  earnings 
was,  therefore,  less  for  the  average  nursing  service  than  for  the  block 
wage-earner  (13.0  per  cent  and  15.9  per  cent  respectively)  ;  but  the 
percentage  of  direct  outlay  to  wage  income  for  illness  was  much  higher 
(7.4  per  cent  and  5.0  per  cent,^  respectively).  This  means  that  for  the 
block  family,  the  proportion  of  income  expended  in  sickness  costs  was 
48  per  cent  larger  for  the  nursing  service  wage-earner  than  for  the 
block  wage-earner.  The  disparity  in  actual,  not  proportionate,  direct 
outlay  was  still  greater.  The  average  cost  of  medical  service  to  the  sick 
block  wage-earner  was  $35.64;  to  the  ill  nursing  service  wage-earner, 
$52.67. 

In  family  as  well  as  individual  sickness  costs,  higher  expenditures 
were  found  with  nursing  service  than  block  families.  The  following 
interesting  comparison  of  the  distribution  of  family  costs  of  nursing 
service  and  block  families  is  made  from  the  data  in  Table  10. 


• 

Distribution  of  family  cost . 

Per  cent  families  with 
sickness  costs. 

Block. 

Nursing 
service. 

Less  than  $50 

51.2 
19.3 
9.0 
5.6 
5.8 
4.0 
2.0 
3.1 

41.8 

$50  but  less  than  $100 ; 

18.3 

$100  but  less  than  $150 

12.7 

$150  but  less  than  $200 

5.2 

$200  but  less  than  $300 

8.2 

$300  but  less  than  $400 

3.7 

$100  but  less  than  $500 

3.4 

$500  and  over , 

6.7 

This  table  clearly  indicates  that  there  is  a  larger  proportion  of  fami- 
lies with  somewhat  higher  costs  of  sickness  among  nursing  service  than 
among  block  families. 

The  data  presented  in  Table  11  make  it  possible  to  analyze  in  a  more 
fundamental  way  this  difference  in  sickness  costs  in  the  two  groups 
studied.  The  average  family  income  (where  there  was  sickness)  of  the 
block  wage-earning  family  was  $1,297.96,  of  the  nursing  service  wage- 

**Pag-e  206. 

®A  study  of  88  wag^e-earners  with  sickness  in  nursing  service  families  showed 
total  wag-e  earnings  of  $62,243   and  total  direct  outlays  of  $4,635.     See  also  p.   207. 


231 

earning  family  $1,273.34,  and  the  average  sickness  costs  of  the  block 
wage-earning  family  was  $97.98,  of  the  nursing  service  wage-earning 
family  $136.72.  In  other  words,  while  the  income  of  nursing  service 
wage-earning  families  was  slightly  lower,  their  illness  outlays  and  losses 
were  39.5  per  cent  higher  than  block  wage-earning  families. 

This  comparison  does  not  tell  the  whole  story.  Although  the  aver- 
age of  lost  wages  in  the  nursing  service  families  was  only  $47.31  as 
against  $54.95  for  the  block  families,  the  average  of  direct  outlays  for 
sickness  was  $89.42  for  the  visiting  nurse  families,  or  over  one  hundred 
per  cent  higher  than  the  average  of  $43.03  for  the  block  families.  It  is 
also  significant  that  with  the  nursing  service  families,  contrary  to  block 
families,  direct  outlays  increased  absolutely  (and  to  a  smaller  degree 
relatively)  with  the  rise  in  the  scale  of  economic  status.  The  averages 
were  $42.52,  $79.85,  and  $112.79  for  families  of  Classes  C,  B  and  A, 
respectively. 

An  analysis  of  the  specific  forms  of  direct  outlays  for  sickness  throws 
further  light  upon  the  higher  cost  of  sickness  with  nursing  service  fami- 
lies. The  average  family  expenditure  was  found  to  be  higher  than  with 
block  families  in  the  amount  paid  physicians  ($62.26  as  against  $45.11)  ; 
for  hospital  bills  ($80.47  as  against  $56.34)  ;  for  medicine  ($19.40  as 
against  $15.91)  ;  and  for  other  outlays  ($18.73  as  against  $12.31).  The 
average  family  outlay  was  higher  in  only  two  items  in  block  than  in 
nursing  service  cases;  in  the  average  amount  paid  nurses  ($29.29  as 
against  $22.57),  and  in  dispensary  fees  per  patient  ($5.40  as  against 
$4.81).  It  is  significant  that  the  percentages  of  families  with  the  differ- 
ent types  of  outlay  were  consistently  much  higher  for  nursing  service 
than  for  block  families  with  sickness  for  every  item  except  "other  out- 
lays;" for  physicians,  92.2  as  compared  with  70.1  per  cent;  for  nurse, 
35.8  per  cent  as  compared  with  4.8  per  cent;  for  hospital,  22.4  as  com- 
pared with  10.4  per  cent;  for  dispensary,  39.2  as  compared  with  7.5  per 
cent;  for  medicine,  90.3  as  compared  w^ith  80.3  per  cent;  and  for  other 
costs  4.1  as  compared  with  11.6  per  cent. 

For  every  dollar  of  family  sickness  cost  38.8  cents  was  charged  to 
payment  of  physicians;  29.9  cents  to  lost  wages;  12.2  cents  to  hospital 
bills;  11.9  cents  to  medicine;  5.5  cents  to  nursing  service;  1.3  cents  to 
dispensary  fees;  0.5  cents  to  other  costs. 

The  question  why  there  were,  on  the  average,  higher  sickness  costs 
with  the  nursing  service  than  with  the  block  wage-earning  family 
($136.72  to  $97.98)-  despite  the  shorter  average  duration  of  sickness  (6.4 
weeks  as  against  7.3  weeks  in  the  case  of  wage-earners)  has  already  been 
raised  but  not  completely  answered.  The  somewhat  larger  size  of  the 
visiting  nurse  family  as  compared  with  the  block  family  (5.1  as  against 
4.1)  is  not  sufficient  explanation.  A  minor  fact  entering  into  the  ex- 
planation is  that  these  cases  included  a  relatively  larger  number  of  cases 
of  serious  illness  among  women  and  children.  Another  is  that  there 
was  a  more  general  observance  of  American  standards.  The  biggest 
factor  is,  however,  that  the  visiting  nurse  educates  the  family  to  a  fuller 
and  more  adequate  utilization  of  the  medical  facilities  in  the  community. 
This  is  shown  by  the  data  relating  to  both  paid  and  free  service. 


232 


(3)  The  Care  of  the  Sich.  ^^^^^m         ^ 
^Ye  have  alread}^  seen  that  a  larger  proportion  of  the  visiting  nurse 

than  of  the  block  families  had  paid  medical  service  last  year.  The  per- 
centage with  free  service  was  also  much  larger  for  the  nursing  service 
group.  For  example,  the  percentages^  with  free  attendance  by  physicians 
was  27.6  for  the  one  group  as  against  13.6  for  the  other;  with  free  nurs- 
ing service  36.0  as  against  6.1 ;  with  free  hospital  care  19.9  as  against 
10.0;  with  free  medicine  1.7  as  against  2.9;  with  free  dispensary  treat- 
ment 31.0  as  against  11.3. 

The  smaller  proportion  of  nursing  service  than  block  families  with- 
out certain  types  of  service  is  indicated  by  the  following  comparisons  i^^ 
without  physician^  except  at  hospitals  or  dispensary,  none  as  against  15.6 
per  cent;  without  nursing  service  except  at  hospital  31.6  as  against  88.8 
per  cent;  without  hospital  care  59.9  as  against  79.1  per  cent;  without 
dispensary  treatment  33.7  as  against  80.7  per  cent;  without  medicine 
16.8  as  against  19.7  {)er  cent.  H 

The  superior  provision  in  medical  treatment  for  nursing  service 
families  was  partially  due,  of  course,  to  the  fact  that  they  were  all  Visit- 
ing J^urse  Association  cases,  and,  therefore,  likely  to  be  placed  in  contact 
with  agencies  providing  free  medical  assistance.  The  extent  of  their 
use  of  medical  facilities  may  be  regarded  as  a  rough  standard  of  the 
minimum  provision  desirable  for  other  families  with  sickness.  The  less 
general  use  of  medical  facilities  by  the  block  families  may  be  taken  as 
a  conservative  index  of  the  inadequacy  of  existing  medical  treatment  of 
sickness  in  wage-earning  families  in  Chicago. 

(4)  Protection  Against  Risks  of  Sickness  and  Death.  ^ 
Insurance  as  a  form  of  protection  against  morbidity  and  mortality 

hazards  is  of  two  general  types :  disability  insurance  against  risk  of  sick- 
ness or  accident  and  life  insurance  providing  for  death  and  funeo'al 
benefits. 

Disability  insurance. — Of  the  total  number,  797,  of  persons  over  14 
years  of  age^-  in  the  nursing  service  families,  435  were  gainfully  occu- 
pied:  408  as  wage-earners  and  27  on  their  own  account.  Of  the  wage- 
earners,  69,  or  16.9  per  cent,  carried  insurance  against  sickness  or  against 
sickness  and  accident.  The  proportion  insured  of  the  smaller  number 
working  on  their  own  account  was  18.5  per  cent.  Both  these  percentages 
are  smaller  than  the  corresponding  figures  in  the  Block  Study  (23.7  per 
cent  of  wage-earners  and  25.8  per  cent  of  the  self-employed).  The 
smaller  relative  number  in  nursing  service  families  insured  is  probablv 
due  to  the  fact  that  they  represent  a  relatively  Americanized  group.  Of 
the  69  wage-earners  59  reported  66  policies  (or  membership  rights), 
for  a  few  were  insured  with  two  or  more  organizations.  The  amount  of 
weekly  benefit  provided  in  the  cases  of  the  59  wage-earners  reporting 
was  for  $5  but  less  than  $10  in  37  cases,  for  $10  but  less  than  $15  in  20 
cases,  and  for  $15  or  over  in  two  cases.  While  the  number  of  the  nursing 
service  wage-earners  insured  was  small,  it  is  significant  to  note  that  the 

»0/See  Text  Table,   p.    243. 
"See  Table  12,  p.  212. 
"See  Table  13,  p.  216. 


233 


proportion  in  the  group  with  weekly  benefits  of  from  $10  but  less  than 
$15  was  much  larger  (33.9  per  cent)  than  for  those  in  the  block  families 
(14.1  per  cent).  A  smaller  relative  number  were  protected  by  disability 
insurance  for  a  somewhat  higher  benefit. 

Of  the  116  wage-earners  sick  for  more  than  a  week,  only  7,  or  ap- 
proximately six  per  cent,  were  reported  as  receiving  benefits  totaling  $313 
or  an  average  of  $44.71.^^  These  figures  stand  over  against  13.4  per 
cent  of  the  wage-earners  sick  in  the  block  studies  receiving  benefits 
averaging  $52.44. 

The  data  thus  far  presented  concern  only  wage-earners.  The  follow- 
ing table  has  been  compiled  from  data  presented  in  Table  15"  to  show 
the  extent  to  which  husbands  of  wage-earning  families,  upon  whom  the 
members  are  more  or*  less  dependent,  were  protected  by  disability  in- 
surance against  the  risks  of  sickness  and  accident: 


Economic  status  of  husbands. 


Number. 


Number 
insured. 


Per  cent 
insured. 


Number 
reporting 

amount 

of 

insurance. 


Average 
amount 

of 
insurance 
per  week. 


A 

122 
83 
43 

248 

33 

20 

9 

62 

27.0 
24.1 
20.9 
25.0 

30 

15 

9 

54 

$9  90 

B 

6.53 

C 

7.00 

All 

8.48 

This  table  shows  the  following  facts : 

(a)  That  while  the  proportion  of  "main  bread  winners"  insured  is 
larger  than  that  of  all  wage-earners  (16.9  per  cent  as  shown  above), 
only  one-fourth  (25.0  per  cent)  had  health  insurance. 

(b)  That  the  percentage  insured  was  much  smaller  than  that  of  the 
husbands  in  wage-earning  families  in  the  blocks  (36.7). 

(c)  That,  as  in  the  block  study,  those  less  able  to  bear  the  costs  of 
sickness  were  less  frequently  protected  and  for  smaller  amounts. 

(d)  And  that  the  average  amount  of  the  insurance  per  week  pro- 
vided for  benefit  was  larger  ($8.48)  than  in  the  case  of  husbands  with 
health  insurance  studied  in  the  blocks  ($6.98). 

Life  insurance.^— A  larger  proportion  of  the  304  nursing  service 
families  (273  or  89.8  per  cent)  as  shown  by  Table  19  than  of  the  block 
families  (81.9  per  cent)  reported  one  or  more  members  insured  against 
the  risk  of  death.  This  is  explained,  in  part  at  least,  by  the  fact  that  the 
Visiting  ?^urse  Association  has  among  its  families  served  those  with 
insurance  with  the  Metropolitan  Life  Insurance  Company.  The  total 
membership  of  the  nursing  service  families  was  1,550  of  whom  1,044,  or 
67.4  per  cent,  were  policyholders.  The  total  number  of  policies  was 
1.142,  or  1.1  policies  per  person  insured.  The  average  value  of  the  1,128 
policies  where  this  fact  was  reported  was  $327.78,  or  ninety  dollars  lower 
than  the  average  amount  per  policy  in  the  block  families  studied.  This 
lower  average  value  of  the  insurance  policies  is  undoubtedly  due  to  the 
larger  proportion  of  children  in  the  nursing  service  than  in  the  block 


13  See  Table  14,  p.   219. 
"See   p.    221. 


234 


TABLE  19— LIFE  INSURANCE  OF  ALL  KINDS  FOR  FAMILIES  IN  THE 
NURSING  SERVICE  STUDY,  BY  NATIONALITY  AND  ECONOMIC  STA- 
TUS. 


Nativity  or  race  of  head  of 
family. 

o 

Number  of  fami- 
lies with  insur- 
ance. 

Per  cent. 

o 

C/3 
(-1 
© 

ss 

o  © 

©t3 
fl  © 

Eh 

Total  number  of 
policyholders. 

Total  number  of 
policies. 

Number  of  policies 
reporting 
amount. 

Total  amount  of 
insurance  re- 
ported. 

Average  amount 
per  policy. 

All  families 

304 

273 

89.8 

1,550 

1,401 

1,044 

1,142 

1,128 

$369,730 

$327. 78 

United  States,  white 

United  States,  colored 

Bohemian 

129 
30 

6 
41 
14 

9 
22 

124 

28 
6 

38 

11 
5 

16 

96.1 
93.3 
100.0 
92.7 
78.6 
55.6 
72.7 

638 

138 
29 

229 
68 
44 

126 

619 
131 
29 
215 
53 
25 
97 

472 
105 
22 
174 
41 
13 
53 

528 
109 
24 
190 
47 
15 
57 

522 
103 
24 
190 
47 
15 
56 

177,044 
22,607 
12,912 
61,340 
17,261 
6,594 
18,226 

339. 16 
219. 49 
538.00 

German 

322.84 

Irish 

367.26 

Italian 

439. 60 

Jewish 

325. 46 

Lithuanian 

Polish 

13 
14 
26 

304 

10 
11 
24 

273 

76.9 
78.6 
92.3 

89.8 

79 

62 

137 

1,550 

62 

45 

125 

1,401 

44 
33 

87 

1.044 

44 
37 
91 

1,142 

44 
36 
91 

1,128 

12,517 
13,913 
27,316 

$369,730 

284.48 

Scandinavian 

386.47 

Other 

300.18 

Economic  status — 

All  families 

$327. 78 

1 

Class  A 

132 
91 
48 

2 
25 

6 

125 
81 
41 

2 
20 

4 

94.7 
89.0 
85.5 
100.0 
80.0 
66.7 

568 
508 
321 

11 
126 

16 

535 
463 
282 

10 
101 

10 

402 

345 

201 

10 

78 
8 

457 

374 

208 

10 

85 

8 

454 

367 

204 

10 

85 
8 

$173,982 

111,090 

47,269 

4,388 

31,474 

1,527 

$383.22 

Class  B 

302. 70 

Class  C 

231. 71 

Class  D 

438.80 

Class  O 

370. 28 

Class  R 

190.88 

235 

families  (average  size  of  the  family  5.1  and  4.1  respectively)  who  almost 
without  exception  carry  the  so-called  "industrial"  insurance  for  relatively 
small  amounts. 

The  distribution  of  insurance  among  families  by  nationality  was 
practically  the  same  as  for  the  block  families  so  far  as  could  be  determined 
by  the  relatively  small  figures  for  the  different  groups.  By  economic 
status  the  slighter  protection  of  families  in  the  poverty  group  is  again 
apparent.  Some  member  of  the  family  was  insured  in  94.7  per  cent  of 
the  "better  off^^  families  in  Class  A,  89.0  per  cent  of  families  in  Class  B 
with  meager  incomes,  and  85.5  per  cent  of  the  poor  families  in  Class  C. 
In  other  words^  while  one  out  of  seven  families  was  without  insurance  in 
Class  C,  approximately  one  out  of  nine  was  without  insurance  in  Class  B, 
and  only  one  out  of  nineteen  in  Class  A.  Taking  the  total  number  of 
members  of  the  families  grouped  into  these  three  classes,  70.8  per  cent 
of  the  first  (A),  67.9  per  cent  of  the  second  (B),  and  62.6  per  cent  of  the 
third. (C)  were  insured.  The  disadvantage  appears  also  in  average  num- 
ber of  policies  per  policyholder — ^Class  A,  1.14;  Class  B,  1.09;  Class  C, 
1.03.  The  average  value  per  policy  for  the  three  classes  was  $383.22, 
$302.70,  $231.71,  respectively.  This  means  that  the  average  amount  of 
insurance  per  policyholder  was  approximately  $437  in  Class  A,  $330  in 
Class  B,  and  $239  in  Class  C. 

The  distribution  of  the  life  insurance  among  members  of  the  family 
as  presented  in  Table  20  brings  out  certain  interesting  comparisons  with 
the  block  families.  While  the  adult  males  were  slightly  better  protected 
by  life  insurance  in  the  visiting  nurse  than  in  the  block  families  (79.4 
per  cent  as  compared  with  74.8  per  cent  for  married  males  and  57.4  per 
cent  as  compared  with  56.5  per  cent  for  unmarried  male  adults),  women 
and  children  were  much  better  insured  in  the  visiting  nurse  than  in  the 
block  families  (71.0  per  cent  as  compared  with  58.8  per  cent  for  married 
females;  66.1  per  cent  with  53.6  per  cent  for  unmarried  female  adults; 
and  62.9  per  cent  with  48.8  per  cent  for  children  14  and  under).  The 
average  value  of  policies  for  persons  insured  in  these  five  groups  was 
$729  for  married  adult  males,  $374  for  married  adult  females,  $312  for 
unmarried  adult  males,  $223  for  unmarried  adult  females,  $96  for 
children  14  years  and  under. 

Of  great  significance  is  the  protection  against  death  in  the  case  of 
male  heads  of  families  as  shown  in  Table  21.  While  of  the  gainfully 
occupied  heads  in  the  blocks  three  in  four  (76.2  per  cent),  in  the  nurs- 
ing service  group  four  in  five  (80.0  per  cent)  were  insured.  The  207 
wage-earning  male  heads  insured  carried  264  policies ;  the  value  of  253  of 
these  was  $181,689,  or  an  average  of  $718  ($14  less  than  the  correspond- 
ing figure  in  the  block  study).  In  other  words,  approximately  80  per 
cent  of  the  wage-earning  male  heads  of  families  were  insured  for  an 
average  of  about  $915  (as  compared  with  $850  for  the  wage-earning  male 
heads  of  families  in  Chicago  blocks). 

The  customary  marked  differences  by  economic  status  are  again 
found  here.  Of  the  male  heads  of  105  families  with  higher  incomes, 
84.0  per  cent  were  insured  for  an  average  of  approximately  $942.98 ;  of 


230 


TABLE    20— DISTRIBUTION    OF    LIFE    INSURANCE    OF    FAMILIES    AMONG 

ALITY  AND  ECO 


Nativity  or  race  of  head 
of  family. 


OT 

•i-H 
I— ( 

s 

Husbands. 

Wives. 

C9 

K 

rm 

CO  ^ 

O 

t3 

'3 

;=:  o 

1 

(1 

t3 

© 

.He 

t-i 
O 

(0 

en 

•^4 

© 

3 

P- 

::5  o 

aa 

<3 

S 

o 

O  bc 

o 

o 

C  tuC 

<o 

1^ 

»^ 

-1^ 

ll 

t-  h: 

-M 

>-> 

(-1 

■•-> 

ll 

t-  3 

a. 

o 

<» 

a 

(U 

©X3 

ct     • 

© 

© 

c 

© 

©•;3 

XJ 

J2 

o 

^ 

XJ  L 

s  © 

ja 

X5 

© 

.Q 

■'^  b 

CU 

S 

a 

u 

s 

s^ 

o  g 

£  3 

a 

a 

« 

a 

3  c 

o 

p^ 

s 

ffi 

3 

s£ 

3 

3 

© 

3 

3  © 

Eh 

^ 

^ 

Ph 

z 

:z^ 

<i 

'Z, 

Z 

P- 

:z 

^^ 

u 

3 
en 


§© 

a« 


All  families. 


United  States,  white. . 
United  States,  colored. 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian 

Other 


Economic  status- 
All  families. . 


Class  A. 
Class  B. 
Class  C. 
Class  D . 
Class  O. 
Class  R . 


1,550 


638 

138 
29 

229 
68 
44 

126 


79 

62 

137 


1,550 


568 
508 
321 

11 
126 

16 


281 


121 
27 

5 
38 
12 

7 
19 


13 
12 
27 


281 


124 
89 
43 


24 
1 


223 


96 

23 
5 

34 
9 
4 

12 


9 
10 
21 


223 


104 
71 
31 


17 


79,4 


79.3 
85.2 
100.0 
89.5 
75.0 
57.1 
63.2 


69.3 
8.3.3 
77.8 


79.4 


83.9 
79.8 
72.1 


70.8 


284 


128 
24 

6 
46 
12 

6 
16 


9 
14 
23 


284 


135 
91 
38 


20 


274 


123 
21 

6 
46 
12 

6 
15 


9 
13 
23 


274 


132 
86 
36 


20 


$199, 747 


$100,887 
6,884 
6,600 
31,720 
8,721 
2,460 
10,800 


5,680 

9,650 

16, 345 


$199, 747 


300 


128 
30 

6 

40 
13 

7 
22 


131 
14 
27 


300 


$98,711 
63,183 
19,493 


18,360 


130 
91 
47 

2 
24 

6 


213 


99 
28 
6 
34 
9 
4 
5 


8 

6 

14 


213 


96 
65 
32 

2 
14 

4 


71.0 


77.3 
93.3 
100.0 
8.5.0 
69.3 
57.1 
22.7 


61.5 
42.9 
51.9 


71.0 


228 


109 
30 
7 
35 
9 
4 
5 


8 

6 

15 


228 


73.8 
71.4 
68.11 
100.0 
58.  3i 
66.7 


105 
68 
32 

2 
17 

4 


224 


108 
27 
7 
35 
9 
4 
5 


$83, 804 


8 

6 

15 


224 


105 
66 
30 

2 
17 

4 


$40, 068 
7,366 
3,700 
12,635 
3,733 
3,350 
1,572 


4,174 
2,262 
4,944 


$83,804 


$40,  539 

22, 038 

11,137 

1,150 

7,985 

955 


237 


MEMBERS  OF  FAMILIES   IN   THE   NURSING   SERVICE   STUDY,   BY  NATION- 
NOMIC  STATUS. 


Unmarried  males  over  14. 

Unmarried  females  over  14. 

Children  14  and  under. 

1 

CO 

CD 

'a 

-sa 

1 

3 
on 

d 

d 

tZ3 

i 

•  <-* 

'o 

rn  ri 

.2  3 

ass 

1 

d 
d 

i 

d 

i 

O 

'o 

«1 

■Sa 

p.  03 

1 

d 

C 

c 

«M 

<M  tuO 

V.t 

r- 

Vh 

■~  M) 

Vh 

d 

v^ 

«M  bc 

^.H 

. 

•^ 

, 

o 

OG 

O 

•^H 

O 

O  d 

o 

O 

o  d 

o 

t. 

ii 

•M 

l-> 

fc-Tj 

+J 

Ui 

Ur 

-1-3 

l-> 

k'f^ 

-^ 

IM 

t-. 

-^ 

Ui 

«h'J3 

•^^ 

<£ 

Ol 

ci 

o 

<Dti 

C5    • 

« 

o 

c 

<0 

<o 

0) 

c 

0 

®"C 

d   • 

X3 

^ 

<D 

J2 

J3  O 

5  ?! 

.C 

^ 

<i> 

X2 

.O  O 

a  o 

Xi 

Xi 

o 

.Q 

X!  O 

d  ? 

a 

a 

O 

a 

a§< 

o  ^ 

a 

o 

ag^ 

s« 

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the  71  with  meager  incomes,  79.8  per  cent,  for  an  average  of  $889.90;  of 
the  31  with  deficient  incomes,  72.1  per  cent,  for  an  average  of  $628.81. 
The  number  of  policies  and  amount  of  insurance  have  been  tabulated 
for  male  heads  by  kind  of  insurance  carrier.  The  number  of  "ordinary 
life'^  policies  was  57,  the  amount  $56,350;  of  "industrial"  polioies,  92, 
the  amount  $38,629;  of  "fraternaP  policies,  69,  the  amount  $59,760; 
of  union  certificates  of  membership  providing  death  benefits,  32,  the 
amount  $23,150;  of  other  forms  of  insurance,  3,  the  amount  $3,800. 
The  largest  number  of  policies,  92,  or  36.3  per  cent,  was  industrial. 
In  aggregate  amount  of  insurance  the  fraternal  carriers  rank  first,  closely 
followed  by  total  amount  of  "ordinary  life  insurance,"  each  of  which 
accounts  for  just  under  one-third  of  the  total  amount  of  insurance 
($59,760  and  $56,350  out  of  a  total  of  $181,689). 

IV.     THE  CHARITY  STUDY. 

Like  the  nursing  service  families,  the  628  charity  families  constitute 
a  selected  group.  But  the  basis  of  selection  is  radically  different.  The 
nursing  service  families  include  not  only  "the  poor,"  and  those  who  in 
the  emergency  of  sickness  are  depressed  to  the  margin  of  poverty,  but 
also  wage-earnings  families  the  majority  of  which  are  above  the  poverty- 
line. 

The  charity  families,  on  the  other  hand,  all  belong  to  the  group  of 
dependents,  partially  or  completely  supported  by  public  or  private  relief. 
The  differentiating  characteristics  of  the  charity  as  compared  with  the 
block  family  grow  out  of  the  causes'  of  dependency.  They,  too,'  are  an 
immigrant  group  and  are  therefore  not  markedly  different  from  the 
block  families  in  composition  by  nativity  and  race. 

The  average  size  of  the  family  is  larger  with  the  charity  group,  but 
large  size  of  the  family  is  one  of  the  causes  or  conditions  of  poverty. 
There  are  a  larger  proportion  of  disrupted  families,  but  death  or  desertion 
of  normal  breadwinner  is  another  of  the  causes  of  poverty.  Then,  too, 
the  normal  economic  status  of  the  majority  of  charity  families  is  in 
Class  C,  because  it  is  easier,  as  we  shall  see  later,  for  poor  families  with 
deficient  incomes  than  for  families  with  larger  incomes  to  descend  the 
economic  scale  into  dependency.  Further  facts  in  regard  to  the  size, 
distribution  by  nationality,  and  family  income  of  the  charity  family 
may  be  found  in  Tables  1,  2,  3,  and  4  in  the  Introduction.^*^ 

Comparisons  with  the  block  and  nursing  service  groups  that  are 
pertinent  will  be  made  in  taking  up  the  analysis  of  the  data  for  the 
charity  families  under  the  headings: 

(1)  Sickness  among  Chicago  wage-earners. 

(2)  The  cost  of  individual  and. of  family  sickness. 

(3)  The  care  of  the  sick. 

(4)  Existing  protection  against  health  hazards. 

(1)   Sickness  Among  Families  in  the  Charity  Group. 

There  are  628  families  and  3,475  persons  in  the  charity  group. 
The  reason  why  serious  sickness,  usually  disabling  for  a  week  or  more, 

*«Pp.    191-97. 


appears  in  613  families,  or  97.6  per  cent  and  with  1,546  peTsons, 
44.5  per  cent  of  the  entire  number,  is  that  only  families  with  sickness 
experience  during  the  year  were  selected  for  study.  In  the  613  families 
with  sickness,  persons  gainfully  occupied  were  ill  in  518,  or  84.5  per 
cent.^''^  In  other  words,  there  were  only  95,  or  15.5  per  cent,  of  the  613 
charity  families  with  sickness  in  which  no  person  gainfully  occupied  wa^ 
sick  as  compared  with  a  similar  percentage  of  44.4  for  the  block  group 
and  59.2  per  cent  for  the  nursing  service  group. 

(2)   Individual  and  Family  Sickness  Costs. 

Of  the  1,546  individuals  sick  in  the  charity  families,  602  were  wage- 
earners,  22  were  self-employed,  and  922  were  non-gainfully  occupied.^" 
Of  708  with  sickness  costs — less  than  half  of  the  number  sick,  632  re- 
ported sickness  costs  in  full,  giving  a  total  of  $110,764  or  $175.26  per 
person.  For  the  wage-earner  sickness  costs  both  in  direct  outlays  and  in 
lost  wages  were  higher  than  for  the  block  and  the  nursing  service  group 
as  indicated  by  the  following  table. 


Number 

wage 

Total 

Direct 

earners 

sickness 

outlays 

Lost  wages 

Group  studied. 

reporting 

costs 

per 

per  wage 

sickness 

per  wage 

wage 

earner. 

costs 

earner. 

earner. 

in  full. 

Block  families 

1,019 
125 

$125. 33 
134. 24 

$24.29 
40.53 

$101. 04 

Nursing  service  families 

93.71 

Charity  families 

447 

233.02 

12.37 

220.65 

This  table  shows  the  much  higher  average  of  sickness  costs  for  the 
charity  than  for  the  block  and  nursing  service  families. 

From  Table  8  a  more  detailed  study  of  comparative  sickness  losses 
is  possible.  Of  the  878  wage-earners  in  the  charity  group,  602  or  68.6 
per  cent  were  sick  as  compared  with  a  percentage  of  35.0  for  the  nursing 
service  wage-earners,  or  27.3  for  the  block  wage-earners.  Of  the  494 
wage-earners  losing  time  because  of  sickness,  450  reported  a  total  of 
7,824  weeks  lost  or  an  average  of  17.4  weeks.  This  long  average  duration 
of  sickness  stands  out  in  marked  contrast  to  the  7.3  weeks  per  block 
wage-earner  ill,  and  6.4  weeks  per  nursing  service  wage-earner  ill.  The 
following  comparative  table  is  of  interest  here. 


Group  studied. 

• 

• 

Wage 

earners 

reporting 

time  lost 

in  full. 

Weeks  lost 

per  wage 

earner. 

Wages  lost 

per  wage 

earner. 

Wages  lost 
per  wage 

earner  per 
week  ill. 

Block  families 

901 
115 
450 

7.3 

6.4 

17.4 

$119. 13 
106.20 
232.20 

$16. 32 

Nursing  service  families : 

16.59 

Charity  families 

13.34 

i"See  Table  6. 
"See  Table  7. 


241 


This  table  shows  that  wages  lost  were  on  the  average  higher  for  the 
block  than  for  the  nursing  service  group,  and  almost  two  times  as  much 
for  charity  as  for  the  block  wage-earner.  'The  heavy  wage-loss  of  the 
charity  wage-earner  was  due  to  the  length  of  illness  not  to  a  higher  wage 
rate  for  this  was  lower. 

Xot  only  was  the  average  wage  loss  higher  in  the  case  of  the  charity 
wage-earner,  but  his  direct  outlays  for  medical  treatment  were  greater 
than  those  of  the  block  wage-earner.  A  comparison  of  direct  sickness 
costs  was  made  possible  by  a  special  study  of  685  block,  88  nursing  service 
and  144  charity  wage-earners  who  w^re  sick  and  who  made  complete  re- 
ports of  direct  outlays  for  medicines  and  medical  treatment.  The 
average  direct  cost  of  illness  for  the  block  wage-earner  was  $35.64,  for 
the  nursing  service  wage-earner  $52.67  and  for  the  charity  wage-earner 
$37.04. 

The  detailed  evidence  of  the  high  wage  losses  is  shown  in  Table  9.^® 
In  comparing  the  charity  with  the  block  and  nursing  service  groups  it  is 
evident  that  the  number  of  charity  wage-earners  tends  to  remain  uniform 
with  the  increase  in  proportion  of  wages  lost,  while  the  number  of  block 
and  nursing  service  wage-earners  tends  to  decrease  with  the  increase  in 
percentage  of  wages  lost.  Of  the  450  charity  wage-earners  losing  a 
week  or  more  on  account  of  illness,  40,  or  8.9  per  cent,  lost  less  than  5 
per  cent  of  their  wages;  61,  or  13.6  per  cent,  lost  5  but  less  than  10  per 
cent;  31,  or  6.9  per  cent,  lost  10  but  less  than  15  per  cent  of  their  wages; 
39,  or  8.7  per  cent,  lost  15  but  less  than  20  per  cent;  58,  or  12.9  per  cent, 
lost  20  but  less  than  30  per  cent;  56,  or  12.4  per  cent,  lost  30  but  less  than 
40  per  cent;  29,  or  6.4  per  cent,  lost  40  but  less  than  50  per  cent;  73,  or 
16.2  per  cent,  lost  50  but  less  than  75  per  cent;  and  63,  or  14.0  per  cent, 
lost  75  per  cent  and  over. 

In  family  sickness  is  included  not  only  the  cost  of  illness  for  the 
wage-earner  but  also  direct  sickness  outlays  for  the  members  of  the  family 
who  are  self-employed,  or  not  gainfully  occupied.  Table  10^^  provides  the 
data  for  the  following  comparative  table  for  the  distribution  of  costs  by 
increasing  amounts  of  outlay  and  wage  losses  because  of  sickness. 


Percentage  of  families  assigned  to 
appropriate  sickness  cost  group. 

Distribution  of  sickness  cost. 

Block 
study. 

Nursing  ser- 
vice study. 

Charity 
study. 

Less  than  $100 . .                                                 

70.5 

29.5 

14.9 

9.1 

5.1 

3.1 

60.1 
39.9 
22.0 
13.8 
10.1 
6.7 

36.8 

$100  and  over .          

63.2 

$200  and  over 

44.8 

$300  and  over                                                        

32.8 

$400  and  over                                                 

22.3 

$500  and  over .    .                                            

14.0 

The  specific  amounts  of  sickness  costs  with  the  family  as  with  the 
individual  were  higher  among  charity  cases  than  among  block  and  nurs- 
ing service  cases. 

^^  See  p.   208. 
'^  See  p.   210. 


—16  H  1 


242 

The  high  cost  of  sickness  among  wage-earning  charity  families  to- 
gether with  their  relative  and  absolute  inability  to  pay  comes  out  most 
forcibly  in  a  study  of  Tabl'e  11.^°  No  wonder  that  sickness  compels 
appeal  for  relief  when  the  average  total  family  income  is  only  $706.31 
and  the  average  total  cost  of  sickness  is  $235.33.  Comparison  of  family 
income  and  family  sickness  costs  with  the  block  and  the  nursing  service 
families  only  sets  off  the  more  unfavorable  situation  of  charity  families 
with  reference  to  th*e  hazards  of  illness.  The  average  income  of  the  char- 
ity family  was  $706.31  as  compared  with  $882.73  for  families  in  Class 
C  with  deficient  incomes  in  the  nursing  service  study  and  $730.43  for 
families  in  Class  C  in  the  blocks.  The  average  cost  of  sickness  per  wage- 
earning  charity  family  (with  sickness)  was  $235.33  as  compared  with 
$136.72  per  wage-earning  nursing  service  family^  or  $97.98  per  wage- 
earning  block  family.  That  the  difference  was  mainly  one  of  lost  wages 
($202.34  for  charity,  $47.31  for  the  nursing  service  and  $54.95  for  block 
wage-earning  family)  is  apparent  when  a  comparison  is  made  of  average 
direct  outlays  (only  $32.99  for  the  charity,  $89.42  for  the  nursing  service, 
and  $43.03  for  the  block  wage-earning  family.) 

A  detailed  analysis  of  the  costs  of  family  sickness  in  the  charity 
group  is  based  upon  the  statistics  presented  in  Table  12.^^  Of  408  fami- 
lies reporting  sickness  costs  in  full,  168,  or  41.2  per  cent,  •  reported  an 
average  of  $39.58  for  attendance  of  phj^sician;  8,  or  2.0  per  cent,  re- 
ported an  average  of  $18.25  for  nursing  service;  46,  or  11.3  per  cent, 
reported  an  average  of  $68.52  for  hospital  bills;  19^  or  4.7  per  cent,  re- 
ported an  average  of  $7.95  for  dispensary  treatment;  210,  or  51.5  per 
cent,  reported  an  average  of  $21.33  for  medicines;  333,  or  81.6  per  cent, 
reported  an  average  of  $254.76  for  lost  wages;  and  35,  or  8.6  per  cent, 
reported  an  average  expenditure  of  $8.97  for  other  costs  of  sickness. 
The  average  sickness  loss  for  each  item  was  higher  in  the  charity  as  com- 
pared with  the  block  families  except  in  expenditure  for  physician  and 
nurse.  In  lost  wages  it  was  about  100  per  cent  higher.  The  proportion 
of  families  with  the  different  items  of  sickness  costs  was  lower  for  the 
charity  families  except  for  lost  wages,  (as  compared  with  block  families) 
for  hospital  treatment,  and  (as  compared  with  nursing  service  families) 
for  "other  expenditures." 

Of  every  dollar  of  sickness  costs  for  these  408  charity  families  85.0 
cents  was  charged  to  lost  wages;  6.7  cents  to  physician;  4.5  cents  to 
medicine;  3.2  to  hospital  bills,  .3  cent  to  other  outlays,  .2  cent  to  dis- 
pensary treatment;  .1  cent  to  nursing  service. 

(3)   The  Care  of  the  SicTc. 

The  most  marked  difference  between  the  care  of  the  sick  in  the 
charity  families  in  comparison  with  the  block  and  nursing  service  families 
is  in  the  larger  proportion  of  free  service.  The  following  table  indicates 
the  chief  types  of  free  service  available  to  the  poor  of  the  city,  and  the 
number  and  percentage  of  families. in  the  three  studies  utilizing  them. 

2«Sce  p.  210. 
21  See  p.   212. 


243 


Kind  of  free  medical  service. 


Number  with  free  medical 
service. 


Block 
study. 


Nursing 

service 

study. 


Charity 
study. 


Per  cent  with  free  medical 
service. 


Block 
study. 


Nursing 
service 
study. 


Charity 
study. 


Total  number 

Physician 

Nurse 

Hospital: 

Medicine 

Dispensary . . . 


2,005 
273 

297 

82 

613 
247 

13.6 

27.6 

122 

107 

166 

6.1 

36.0 

201 

59 

276 

10.0 

19.9 

59 

5 

80 

2.9 

1.7 

226 

92 

239 

11.3 

31.0 

40.3 
27.1 
45.0 
13.1 
39.0 


Except  for  free  nursing,  in  which  naturally  the  nursing  service 
group  has  the  largest  proportion,  the  charity  families  had  the  highest 
percentage  for  each  of  the  kinds  of  free  medical  service. 

(4)   Existing  Protection  Against  Health  Hazards. 

The  charity  group  is  made  up  of  those  in  greatest  need.  Charity 
families  sustained  heavier  burdens  of  sickness  than  those  in  the  block 
and  nursing  service  studies.  It  is  important  to  ascertain  whether  these 
who  are  least  able  to  bear  the  costs  of  illness  and  death  were  more  or  less 
protected  by  health  and  life  insurance  than  families  better  off  econom- 
ically. Conditions  are  particularly  favorable  for  this  study  because  of 
the  reliability  of  the  returns  on  disability  and  life  insurance  secured  in 
each  instance,  both  from  a  visit  to  the  families  and  from  prior  con- 
sultation of  the  records  of  charitable  agencies. 

Disability  insurance. — ^The  smaller  number  of  charity  than  of 
nursing  service  and  block  families  protected  by  health  insurance  is  ex- 
hibited in  the  following  table : 

PERSONS  OVER   14   YEARS  OF  AGE  CLASSIFIED  BY  INDUSTRIAL.  STATUS. 


Wage  earners. 

Self  employed. 

Non-gainfully   occupied. 

Group  studied. 

Num- 
ber. 

Per 

cent 
with 
health 
insur- 
ance. 

Aver- 
age 
amount 
weekly 
benefit 

pro- 
vided. 

Num- 
ber. 

Per 
cent 
with 
health 
insur- 
ance. 

Aver- 
age 
amount 
weekly 
benefit 

pro- 
vided. 

Num- 
ber. 

Per 
cent 
with 
health 
insur- 
ance. 

Aver- 
age 
amount 
weekly 
benefit 

pro- 
vided. 

Block  families 

4,456 
408 
859 

23.7 
16.9 
11.6 

$6.79 
8.46 
5.52 

345 
27 
27 

25.8 

18.5 

7.4 

$7.40 
9.75 
5.00 

2,979 
362 
557 

8.8 

.    5.2 

4.8 

4.68 

Nursing  service  families.. 
Charity  families 

7.17 
6.13 

The  statistical  facts  here  presented  show : 

(1)  The  relative  number  of  insured  persons  over  14  years  of  age  in 
the  charity  group  (no  matter  what  their  industrial  status)  was  smaller 
than  among  the  nursing  service  families  and  still  smaller  than  among 
the  block  families. 

(2)  The  average  amount  of  weekly  benefit  provided  by  policies  (or 
membership  rights)  was  less  for  charity  families  (regardless  of  economic 


244 


status)  than  for  block  families  and  much  less  than  for  nursing  service 
families. 

(3)  So  far  as  wage-earners  are  concerned,  only  11.6  per  cent  were 
insured  for  benefits  averaging  $5.52  a  week,  as  against  16.9  per  cent  for 
an  average  weekly  bnefit  of  $8.46  in  the  nursing  service  group^  and  23.7 
per  cent  for  $6.79  in  the  block  family  group. 

The  relative  number  insured  grouped  by  nationality  of  head  of  the 
the  wage-earning  family  does  not  differ  markedly  from  the  proportion 
found  in  the  block  study.  The  proportion  insured  is  highest  with  the 
United  States  Colored  and  lowest  with  the  Irish.  Differences  according 
to  the  presumable  effect  of  the  pressure  of  poverty  are  perceived  in  the 
small  decline  in  the  proportion  insured  Avith  United  States  Colored,  Jew- 
ish, and  German  wage-earners,  and  the  great  reduction  with  United 
States  White,  Pole,  Italian  and  Scandinavian.    . 

A  comparison  is  offered  in  the  following  table^^  of  the  health  in- 
surance carried  by  wage-earners  within  the  block,  nursing  service,  and 
charity  groups. 


Group  studied. 


Num- 
ber 
wage 
earners. 

Num- 
ber 
losing 
wages 

for 

more 

than 

one 

week. 

Per 

cent 

wage 

earners 

losing 

wages. 

Num- 
ber 
paid 
sick 

bene- 
fits. 

Per 

cent  of 
sick 
paid 
bene- 
fits. 

Aver- 
age 
loss 
per 

man. 

Aver- 
age 
benefit 

re- 
ceived. 

Per 

cent  of 
benefit 
of  wage 
loss. 


Block  families 

Nursing  service  families 
Charity  families 


4,474 

937 

20.9 

126 

13.4 

*$118.  76 

$52. 44 

409 

116 

28.4 

7 

6.0 

106.  20 

44.71 

878 

494 

56.3 

54 

10.9 

*231.  22 

55.57 

44.1 
42.1 
24.0 


*  The  number  of  wage-earners  reporting  completely  for  the  data  presented  in 
Table  14  is  somewhat  larger  than  the  number  making  complete  returns  for  data 
in  Table  8. 

Significant  facts  indicated  by  this  table  are :  ( 1 )  that  the  per  cent 
of  sick  wage-earners  paid  benefits  was  smaller  with  the  charity  than  with 
the  block  group  (10.9  to  13.4)  ;  the  per  cent,  however,  for  the  nursing 
service  families  was  still  lower  (6.0  per  cent)  ;  (2)  that,  although  the 
average  wage  loss  of  the  charity  wage-earner  was  almost  double  that  of 
the  block  wage-earner,  the  average  amount  of  sickness  benefit  received 
was  only  slightly  larger  ($55.57  to  $52.44)  and  the  per  cent  of  benefit 
received  to  wage  loss  of  the  charity  wage-earner  (24.0)  was  slightly  more 
than  half  that  of  the  nursing  service  (42.1)  and  block  wage-earner 
(44.1). 

Of  the  54  wage-earners  receiving  sick  benefits,  51  stated  59  sources. 
The  larger  number  of  these  (29)  received  benefits  from  fraternal  orders, 
followed  by  unions  (13),  commercial  insurance  agencies  (9),  and 
establishment  funds  (8). 


22 


This  is  a  summary  table  based  upon  data  in  Table  14,  p.   219. 


245 


A  comparison  of  the  health  insurance  carried  by  wage-earning 
husbands  with  famil^y  responsibilities  in  the  charity,  nursing  service,  and 
block  families  is  given  in  the  following  table.^^ 


Group  studied. 


Number 

of 
husbands. 


Number 
insured. 


Per  cent 
insured. 


Number 

reporting 

amount 

of 

insurance. 


Average 
amount 

of 
insurance 
per  week. 


Block  families 

Nursing  service  families 
Charity  families 


2,315 

850 

36.7 

788 

248 

62 

25.0 

54 

421 

84 

20.0 

69 

$6.98 
8.48 
5.93 


This  table  shows  that  the  main  breadwinner  in  the  charity  family 
had  less  relative  protection  against  risk  of  sickness  both  in  the  percentage 
insured  (20.0  as  against  25.0  with  the  nursing  service  and  36.7  with  the 
block  groups)  and  in  the  benefit  provided  ($5.93  as  against  $6.98  with 
the  block  and  $8.48  with  the  nursing  service  main  breadwinner). 

Three  tables  have  now  been  presented  showing  by  block,  nursing 
service,  and  charity  groups  disability  insurance  for  all  persons  over  14 
years  of  age,  all  wage-earners,  and  wage-earning  husbands.  Obvious 
differences  have  been  commented  on.  The  contrasts  pointed  out  between 
the  charity  and  the  block  families  are  only  those  which  w^ould  be  expected 
in  view  of  the  lower  normal  economic  status  of  the  former  and  the  pro- 
tection health  insurance  is  supposed  to  give  against  dependency.  It  is 
important  to  note  in  this  connection  the  unusually  large  percentage 
(63,9)^*  of  the  charity  families  in  Class  C.  The  relatively  smaller  num- 
ber insured  among  those  in  the  lowest  economic  group  (Class  C)  will  be 
recalled.  As  already  seen,  in  the  block  studies  38.3  per  cent  of  the  hus- 
bands in  Class  A  and  39.2  por  cent  of  those  in  Class  B  as  against  24.2 
per  cent  in  Class  C  had  health  insurance.  With  the  great  majority 
of  the  dependent  families  drawn  from  Class  C  (normal  status)  the 
most  significant  thing  shown  by  the  tables  is  that  among  the  de- 
pendent 11.6  per  cent  of  the  wage-earners  had  health  insurance  with 
benefits  averaging  $5.52  per  week,  that  20  per  cent  of  the  wage-earning 
husbands  had  insurance  averaging  $5.91  per  week,  and  that  10.9  per  cent 
of  the  wage-earners  with  sickness  during  the  year  had  drawn  benefits 
averaging  $55.57 — evidently  for  an  average  of  about  10  weeks  in  the 
year.  While  it  may  be  that  for  every  case  of  dependency  in  spite  of 
health  insurance  carried,  another  case  was  prevented,  it  is  obvious  that 
health  insurance  in  the  amounts  and  of  the  kind  carried  did  not  serve  as 
an  adequate  safeguard  against  dependency  as  a  result  of  the  disabilities 
sustained.  As  will  be  shown  later  most  of  the  illnesses  resulting  in  de- 
pendency were  of  a  chronic  type;  most  of  the  insurance  now  provided  is 
limited  to  a  fraction  of  the  year,  and  is  for  small  sums  per  week.  What- 
ever might  be  accomplished  in  preventing  dependency  by  health  insur- 
ance covering  a  longer  period  and  paying  larger  benefits  than  $5.52  per 


23  The  data  presented  are  based  upon  Table  15  p.  221. 
^*  Supra,  p.  276. 


24G 


TABKE    22 — LIFE    INSURANCE     OP    ALL    KINDS     FOR    FAMILIES    IN     THE 

CHARITY    STUDY,    BY   NATIONALITY. 


Nativity  of  race  of  head  of 
family. 


<«-( 

5R 

.      1 

o 

«i-i 

VH 

o 

Vh 

o 

m 

°m 

O 

o 

o 

Ut 

II 

«-  h 

l-i 

;=) 

-M  A 

o 
^ 

^.S 

o 

ft.. 

otal  amoun 
insurance  r 
ported. 

•30 

umber  of 
lies  with 
ance. 

© 

a- 

otal  num 
policyho] 

otal  num 
policies. 

umber  of 
reporting 
amount. 

&H 

Z 

Pn 

H 

H 

Eh 

Eh 

Z 

Eh 

a>. 

I— ( 

®  o 

Sfft 
>  ft 


All  families 

United  States,  white . 
United  States,  colored 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian 

Other 


628 

444 

70.7 

3,475 

115 

91 

79.1 

590 

23 

21 

91.3 

128 

15 

12 

80.0 

92 

69 

51 

73.9 

355 

46 

36 

78.3 

211 

79 

31 

39.2 

507 

39 

17 

43.6 

221 

8 

5 

62.5 

41 

126 

104 

82.5 

776 

27 

18 

66.7 

113 

81 

58 

71.6 

441 

2,480 


471 
119 

72 
265 
171 
210 
101  i 

27 
6451 

75 
324 


1,720 


358 
90 
47 

210 

141 
96 
22 
17 

444 
52 

243 


1,810 


383 
98 
50 

220 

151 
97 
23 
19 

455 
52 

262 


1,714 


380 
88 
50 

205 

143 
91 
20 
19 

429 
44 

245 


$374,084 


$86,978 

13,074 

15,206 

41,583 

33, 861 

18,385 

8,971 

4,598 

99,605 

9,117 

42,706 


$218.  25 


$228. 89 
148.  57 
304.12 
202. 36 
236.79 
202. 03 
448. 55 
242.00 
232. 18 
207.  20 
174.  31 


247 

week,  health  insurance  covering  only  24  per  cent  of  wage  losses  and  a 
smaller  percentage  of  the  larger  sickness  costs  does  not  prevent  poverty 
in  a  relatively  large  number  of  cases. 

Life  insurance. — The  following  table^^  presents  a  comparison  for  the 
three  groups  studied  of  the  proportion  of  families  and  of  persons  with 
life  insurance  and  the  average  amount  of  death  or  funeral  benefits  per 
policy  and  per  person. 


Group  studied. 


Average 

Average 

Per  cent 

Total 

Per 

number 

amount 

Total 

with  in- 

members 

cent 

policies 

of  in- 

families. 

surance. 

of 

insured. 

per 

surance 

families. 

person 
insured. 

per 
policy. 

Average 
amount 

of  in- 
surance 
per 

person 
insured 
(approxi- 
mately.) 


Block  study 

Nursing  service  study 
Charity  study 


3,048 

81.9 

12,450 

57.8 

1.07 

$419. 24 

304 

89.8 

1,550 

67.4 

1.09 

327. 78 

628 

70.7 

3,475 

49.5 

1.05 

218. 25 

1449 
357 
229 


The  table  indicates  that  the  charity  families  were  the  least  pro- 
tected in  the  following  ways :  ( 1 )  in  per  cent  of  families  with  one  or  more 
members  insured  and  in  proportion  of  their  members  insured;  (2)  in 
average  number  of  policies  per  person;  (3)  in  average  value  of  policy, 
and  in  the  average  amount  of  insurance  per  person. 

The  relative  numbers  by  nationality  of  heads  of  families  with  one  or 
more  members  insured  differ,  though  not  markedly,  yet  quite  significantly 
as  indicated  by  the  data  presented  in  Table  22.  The  order  of  nationality 
with  reference  to  proportion  of  families  with  life  insurance  was  prac- 
tically the  same  as  in  the  block  study^^  with  the  United  States  Colored 
at  the  top  and  the  Italians  at  the  bottom  of  the  scale.  The  per  cent 
deviation  by  proportion  insured  according  to  nationality  of  the  charity 
families  from  the  corresponding  relative  numbers  of  the  block  families 
is  important  as  indicating  the  degree  to  which  poverty  and  dependency 
affect  both  the  foregoing  and  (when  once  assumed)  the  surrender  of  the 
protection  of  insurance.  The  extent  to  which  the  proportion  of  charity 
families  with  insurance  was  lower  than  that  of  the  block  families  with 
insurance  is  indicated  by  the  following  groups :  under  10  per  cent  lower, 
United  States  Colored,  "Other  Nationalities,^^  Polish,  United  States 
White;  from  10  to  24  per  cent  lower,  Bohemian,  German,  Irish,  Scan- 
dinavian, Lithuanian ;  from  25  to  35  per  cent  lower,  Jewish  and  Italian. 

In  this  connection  it  is  significant  to  note  that  the  proportion  of 
families  with  life  insurance  was  found  to  be  lowest  in  all  three  studies 
with  Jews  and  Italians. 


25  Based  on  data  in  Table  16,  p. 
^^  See  p.   223. 


223 


;  Table  19,  p.  234;  Table  22,  p.  246. 


248 


TABLE    23 — DISTRIBUTION    OF    LIFE    INSURANCE    OF    FAMILIES    AMONG 


Nativity  or  race  of  head  of 
family. 


a 

Husbands. 

Wives 

a 

CS 

OH 
OH 

§ 

CO 

© 

o 

o 

o 

.S  3 

=3a 

CO 

o 
o 

Xi 

3 

ft 

ftCS 

d 

ft 

ft<3 

i 

n 

U 

•»H 

->j 

Oh 

o 

rof 
ting 

OH 

o 

1.^ 

.|H 
(H 

-(-» 

o 

rof 
ting 

<£> 

» 

rt 

<x> 

«  I-, 

fl  ,? 

<D 

« 

fl 

© 

©     «H 

X5 

XJ 

o 

Xi 

Xi  6 

3  s 

Xi 

X2 

© 

,Q 

XJ  o 

eJ 

E 

a 

o 

a 

a  e* 

B  03 

a 

a 

« 

a 

a.^ 

o 

f 

d 

© 

d  ui 

3 

d 

© 

d 

d  £. 

&H 

55 

;z; 

f^ 

;z; 

J2; 

<5 

;z^ 

^ 

(=4 

^ 

Z 

d 

CO 

d 


aS 


All  families 

United  States,  white . 
United  States,  colored 

Bohemian 

German 

Irish 

Italian 

Jewish 

Lithuanian 

Polish 

Scandinavian 

Other 


3,475 

520 

300 

57.7 

338 

305 

$152,447 

622 

305  49.  0 

323 

267 

590 

98 

68 

69.4 

81 

81 

$39,452 

113 

73  64.6 

•76 

73 

128 

20 

18 

90.0 

21 

18 

4,007 

23 

18,78.3 

18 

12 

92 

11 

7 

63.6 

9 

9 

6,100 

15 

9  60.0 

10 

10 

355 

51 

35 

68.6 

39 

32 

14,217 

69 

40158. 0 

42 

36 

211 

37 

25 

67.6 

27 

25 

14,057 

44 

29  65.9 

30 

24 

507 

72 

18 

25.0 

19 

15 

8,851 

79 

8 

10.1 

8 

6 

221 

36 

13 

36.1 

14 

11 

7,200 

39 

3 

7.7 

3 

3 

41 

6 

1 

16.7 

1 

1 

2,000 

8 

3 

37.5 

5 

5 

776 

107 

71 

66.4 

77 

69 

40, 130 

125 

69 

55.2 

74 

56 

113 

19 

12 

63.2 

12 

9 

3,956 

27 

12 

44.4 

12 

7 

441 

63 

32 

50.8 

38 

35 

12,477 

80 

41 

51.3 

45 

35 

$90,463 

$20, 944 
3,099 
4,830 

10,021 
9,479 
1,376 
1,125 
1,609 

24,883 
1,377 

11,720 


249 


MEMBERS    OF    FAMILIES    IN    THE    CHARITY    STUDY.    BY    NATIONALITY. 


Unmarried  males  over  14. 

Unmarried  females  over  14. 

Children  14  and  under. 

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56.1 

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29,476 

10 

6 

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1,915 

14 

12 

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2,796 

276 

154 

55.8 

162 

158 

13,948 

250 


Noteworthy  also  is  the  deviation  from  the  block  and  nursing  service 
families  according  to  relative  numbers  of  the  different  members  of  the 
family  with  insurance  as  shown  in  the  following  table. 


27 


Group  studied. 


Husbands. 


Wives. 


Unmarried 

males  over 

14  years. 


Unmarried 
females 
over  14. 


Children 
14  and 
under. 


PER  CENT  INSURED. 

Block  study 

Nursing  ser\ace  study 

Charity  study 

AVERAGE  AMOUNT  OF  POLICY 

Block  study 

Nursing  service  study 

Charity  study 


74.8 

58.8 

56.5 

53.6 

79.4 

71.0 

57.4 

66.1 

57.7 

49.0 

38.8 

51.0 

$758 

$474 

$423 

$307 

729 

374 

312 

223 

500 

339 

223 

226 

48.8 
62.9 
48.2 


$101 

96 

100 


Two  chief  conclusions  may  be  drawn  from  a  comparison  of  the  block 
and  the  charity  families : 

(1)  That  protection  against  death  was  most  greatly  reduced  in  the 
charity  cases  where  it  is  in  reality  most  essential  (with  husbands,  wives 
and  unmarried  adult  males)  and  retained  where  the  risk  of  death  might 
more  easily  be  met  without  it  (with  unmarried  adult  females  and  with 
children  14  years  of  age  and  under) . 

(2)  That  the  charity  families  were  at  a  further  disadvantage  in  the 
decidedly,  smaller  amount  of  the  policy  with  both  husbands  and  un- 
married males  over  14. 

The  data  in  regard  to  the  kind  and  amount  of  insurance  of  male  heads 
of  wage-earning  families  (those  in  Classes  A,  B,  C,  and  D)  deserve 
special  study.  The  table^^  which  follows  exhibits  a  comparison  of  the 
charity  with  the  block  and  the  nursing  service  families. 


Male  heads  of  wage- 
earning  families. 

Insurance  carried. 

Group  studied. 

Total 
number. 

Per  cent 
insured. 

Policies 

per 
person. 

Average  amoimt  of 
insurance. 

Per 

person 
insured 
and  not 

p 

Per 
policy. 

Per  person 
insured. 

insured. 

Block  families 

2,417 
237 
415 

77.2 
80.5 
56.9 

1.16 
1.28 
1.06 

$732 
718 
529 

$850 
915 
561 

$656 

Nursing  service  families 

Charity  families 

737 
319 

It  is  evident  from  an  analysis  of  this  table  that  little  over  one-half 
(56.9  per  cent)  of  the  wage-earning  male  heads  of  charity  families  had 
insurance,  and  that  they  had  (when  contrasted  with  main  breadwinners 
and  nursing  service  families)  less  policies  per  person  for  a  much  smaller 
average  amount  of  insurance  per  policy,  per  male  head  insured,  and  per 
wage-earning  male  head  whether  or  not  insured. 

^'f  Based  on  data  in  Table  17  pp.  224-25  ;  Table  20,  pp.  236-37  ;  and  Table  23,  pp. 
248-49. 

2s  Based  on  data  in  Table  18,  p.  228;  Table  21,  p.  238;  and  Table  24,  p.  251. 


251 


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Finally,  a  comparison  of  the  type  of  insurance  carried  by  male  wage- 
earning  heads  of  block,  nursing  service,  and  charity  families  may  be  ex- 
pected to  throw  further  light  upon  the  effect  of  dependency  upon  pro;^ 
tectio'n  against  the  risk  of  death.  The  following  table-^  shows  proportion 
of  policies  and  of  amount  of  insurance  carried  by  the  different  types  of 
organizations. 


Number  policies  re- 
porting type. 

Per  cent  particular  type  of 
policy  of  all  types. 

Amount  of  insurance 
reported. 

Per  cent  of  total  amount  of 
insurance. 

Group  studied. 

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>> 

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3 

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1— 

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0 

BIocls;  families 

Nursing  sersdce 
families 

1,908 

253 

222 

10.8 

22.5 
4.1 

30.3 

36.4 
52.7 

49.9 

27.3 
33.3 

6.0 

12.6 

7.7 

3.0 

1.2 
2.2 

$1,396,653 

181,689 
117,524 

19.3 

31.0 

7:2 

20.5 

21.3 
35.7 

53.3 

32.9 
49.7 

4.9 

12.7 
6.3 

2.0 
2.1 

Charity  families 

1.1 

The  groups  studied  show  characteristic  differences  in  per  cent  of 
insurance  policies  carried: 

(1)  The  large  proportion'  of  fraternal  policies  with  the  block  fami- 
lies is,  to  a  considerable  extent,  the  result  of  the  hold  of  immigrant 
societies   providing   insurance. 

(2)  The  much  larger  percentage  of  ordinary  life  insurance  with  the 
nursing  service  families  is  to  be  correlated  with  their  more  American 
character. 

(3)  The  larger  proportion  of  industrial  policies  with  the  charity 
families  means  that  these  are  evidentlv  the  last  to  be  surrendered  under 
the  pressure  of  poverty  and  dependency. 


Y.    SICKNESS  AS  A  CAUSE  OF  POA^ERTY  AND  DEPENDENCY. 

INTRODUCTION. 

Sickness  is  not  solely  a  medical  problem,  for  disabling  illness  of  the 
wage-earner  means  unemployment  with  loss  of  wages.  The  high  cost 
of  medical  treatment  and  the  reduction  of  income  by  the  sickness  of  the 
wage-earner  result  almost  invariably  in  economic  strain  and  privation, 
frequently  in  lowered  standards  of  living,  too  often  in  poverty  and  not 
infrequently  in  dependency.  This  relation  of  sickness  to  lowered 
standards  of  living,  to  poverty,  and  to  dependency  is  a  matter  of  common 
observation.  However,  an  understanding  of  the  nature  and  extent  of  the 
poverty  and  the  dependency  consequent  upon  sickness  requires  a  survey 
of  large  numbers  of  persons  and  an  intensive  study  of  the  effects  of 
specific  diseases.  To  secure  as  exact  information  as  possible  concerning 
the  relation  of  sickness  to  poverty  and  dependency  the  Commission  made 
a  special  investigation  of  this  problem. 

2»  Based  on  data  in  Tables  18,  21,  24. 


253 

The  investigation  made  included  five  sections,  as  follows : 

(1)  A  brief  summary  of  the  literature  dealing  with  the  relation  of 
sickness  to  poverty  and  dependency. 

(2)  A  study  of  sickness  as  a  cause  of  dependency  in  eight  Illinois 
cities  outside  of  Chicago  based  upon  the  returns  from  a  questionnaire 
sent  out  by  the  Commission  to  the  superintendents  of  the  various  charity 
organization  societies  in  the  State. 

(3)  A  study  of  the  relation  of  sickness  to  dependency  in  Chicago 
and  Cook  County  through  an  analysis  of  the  data  in  the  annual  reports 
and  records  of  the  United  Charities,  Jewish  Aid  Society,  and  Cook 
County  Agent. 

(4)  An  analysis  of  the  nature  and  extent  of  sickness  as  a  cause  of 
dependency  in  the  628  charity  families  of  the  Family  Study. 

(5)  A  study  of  sickness  as  a  cause  of  lowered  economic  status  and  of 
poverty  in  the  2,708  wage-earning  families  in  the  41  blocks  of  the  Family 
Study. 

(1)  A  Summary  of  the  Literature  upon  Sickness  as  a  Cause  of  De- 
pendency and  Poverty. 

The  three  important  sources  of  information  bearing  upon  the 
problem  of  the  relation  of  sickness  to  poverty  in  the  United  States  are 
to  be  found  in  the  investigations  of  Amos  G.  Warner,  of  E.  T.  Devine,  and 
of  the  Immigration  Commission  in  its  report  on  "Immigrants  as  Charity 
Seekers." 

Warner  in  his  "American  Charities'^  presents  the  results  of  his 
survey  of  the  causes  of  poverty  as  found  for  1890-92  in  the  records  of 
charity  organization  societies  in  four  cities  of  the  United  States.  He 
concludes,  "Sickness,  though  not  the  largest,  is  the  most  constant  cause 
of  poverty  everywhere  and  at  all  times,  *  *  *  ^^^  according  to  all 
investigators.'  In  both  American  and  English  experience  the  percentage 
sinks  but  once  as  low  as  15  and  never  quite  reaches  28,  the  average  being 
21.  This  is  one  of  the  most  significant  facts  brought  out  by  these  statis- 
tics and  one  not  anticipated  bv  the  writer  when  he  began  collating 
them."3o 

Devine  in  his  ^"Misery  and  Its  Causes"  presents  the  results  of  his 
inquiry  in  New  York  "into  the  conditions  present  in  five  thousand  fami- 
lies who  came  under  the  care  of  the  district  committees  of  the  Charity 
Organization  Society  in  the  two  years  ending  September  30,  1908."  He 
concludes,  "111  health  is  perhaps  the  most  constant  of  the  attendants  of 
poverty.  It  has  been  customary  to  say  that  25  per  cent  of  the  distress 
known  to  charitable  societies  is  caused  by  sickness.  An  inquiry  into  the 
physical  condition  of  the  members  of  the  families  that  ask  for  aid,  with- 
out for  the  moment  taking  any  other  complications  into  account,  clearly 
indicates  that  whether  it  be  the  first  cause  or  merely  a  complication  from 
the  effect  of  other  causes,  physical  disability  is  at  any  rate  a  very  serious 
disabling  condition  at  the  time  of  application  in  three-fourths — not  one- 
fourth — of  all  the  families  that  come  under  the  care  of  the  Chnrifv 


***  Warner,  American  Charities,  p.   51. 


254 

Organization  Society — who  are  probably  in  this  respect  in  no  degree  ex- 
ceptional among  families  in  need  of  charitable  aid."^^ 

The  most  extensive  survey  of  dependency  in  the  United  States  was 
made  in  connection  with  the  study  of  Immigrants  as  Charity  Seekers 
by  the  Immigration  Commission,  1907-10.  The  investigation  covered  all 
recipients  of  charity,  native  as  well  as  foreign-born,  receiving  assistance 
from  charit}^  organization  societies  in  43  cities  of  the  United  States  dur- 
ing the  six  months  from  December  1,  1908  to  May  31,  1909.  The  total 
number  of  families  furnishing  complete  data  was  31,374.  The  total 
number  of  persons  in  these  cases  was  118,299.^^  For  each  family,  in- 
formation was  secured  for  the  apparent  cause  or  causes  of  need. 

The  apparent  cause  of  need  is  ascribed  to  "illness  of  breadwinnner" 
in  20.8  per  cent  of  the  families,  and  to  "illness  of  another  member  of  the 
family"  in  17.6  per  cent  of  the  cases.  If  the  number  of  persons  in  these 
families  is  taken  as  the  basis  for  determining  the  proportion,  we  find 
that  the  report  assigns  as  a  cause  of  need  "illness  of  breadwinner"  in 
19.7  per  cent  and  "illness  of  another  member  of  the  family" 'in  21.7  per 
cent.  The  addition  of  the  percentages  where  the  cause  of  need  is  either 
"illness  of  breadwinner"  or  illness  of  another  member  of  the  family"  in 
order  to  determine  the  proportion  of  families  or  persons  where  sickness 
is  the  apparent  cause  of  need  is  not  permissible  because  of  the  fact  that 
for  many  of  the  families  more  than  one  cause  was  reported.  The  total 
of  the  causes  of  need  is  fifty  per  cent  higher  than  the  number  of  cases  or 
of  persons  involved.^^ 

That  these  three  studies  by  Warner,  Devine,  and  the  Immigration 
Commission  are  not  comparable  is  evident.  As  the  basis  of  com- 
parison Warner  used  the  "chief  cause"  of  dependency;  Devine  analyzed 
"conditions  which  accompany  destitution"  with  no  effort  to  deter- 
mine their  relative  weight  as  causes  of  dependency;  and  the  Immi- 
gration Commission  sought  to  ascribe  dependency  to  the  chief  "apparent 
causes  of  need."  A  straight  comparison  between  these  studies  is  there- 
fore impossible.  ,  Nevertheless  a  close  if  not  exact  common  basis  may 
be  secured  by  considering  the  ratio  of  the  causes  and  of  the  conditions 
■attributed  to  sickness  to  the  sum  total  of  the  assigned  causes  and  con- 
ditions of  dependency.  The  following  table  offers  a  comparative  analysis 
of  the  studies  by  Warner,  Devine  and  the  Immigration  Commission  pre- 
sented in  this  way: 

"  Devine,  Misery  and  Its  Causes,  p.  54. 

22  The  Immigration   Commission,  Report,  Vol.  II,  pp.    120-123. 

33  Immigration  Commission,  Report,  Vol.  II,  p.   115. 


255 


Total 

Number  of 

families 

or  cases 

studied. 

Sum  total 

of 
all  causes 

or 
conditions 

of  de- 
pendency. 

Number  of 

families 
or  cases  in 

which 
sickness  is 

(a)  "chief 
cause" 

(Warner); 

(b)  "con- 
dition" 

(Devine); 
(c)  "appar- 
ent causes 
of  need" 
(Immigra- 
tion com- 
mission.) 

Percentage  where 

the  assigned  cause  or 

condition  of 

dependency  is 

sickness. 

study  of  dependency. 

Of  total 
number 

of 
cases. 

Of  total 

causes 

or 

conditions. 

Warner.    Study  of  7,225  cases  from  chari- 
ty organization  societies  of  4  American 
cities 

7,225 
5,000 
1,000 

31,374 
*118,299 

7,225 

16,944 

3,040 

26.8 

79.5 

76.4 

/        t20. 8 

1     :i7.6 

/        ,tl9. 7 
\         ^21. 7 

26.8 

Devine.    Study  of  5,000  dependent  fami- 
nes in  New  York  City,  1906-08 

Devine.    Study  of  1,000  dependent  fami- 
lies in  New  York  City,  1906-07 

Immigration  Commission.   Study  of  char- 
ity seekers.    31,374  cases 

3,876 
764 

22.9 
25.1 

}        *=^5.5 
j        **26. 6 

Immigration  Commission.   Study  of  char- 
ity seekers.    118,299  persons  in  these 
families 

*  Persons. 

t,  t  The  first  percentage  (t)  refers  to  "illness  of  bread-winners"  and  the  second 
percentage  (t)  refers  to  "illness  of  another  member  of  the  family."  These  per- 
centages, as  explained  earlier  in  the  text  could  not  be  combined  and  so  are  pre- 
sented separately. 

**  The  Immigration  Commission  made  separate  tabulations  of  families  and  of 
persons  in  these  families.;  for  that  reason  the  percentages  for  each  are  given. 

It  is  evident  from  an  examination  of  this  table  that  in  all  these  in- 
vestigations sickness,  whether  designated  as  chief  cause,  or  a  cause,  or  a 
condition  among  other  causes  or  conditions,  maintains  a  fairly  constant 
ratio  of  one  in  four  of  the  sum  total  of  causes  and  conditions  of  de- 
pendency. One-fourth  of  poverty  of  the  type  of  dependency  is,  then, 
either  primarily  the  result  of  physical  disability  (Warner),  or  physical 
disability  as  an  apparent  cause  of  need  or  a  condition  accompanying 
dependency  appears  once  in  four  times  among  all  causes  and  conditions 
(Devine  and  the  Immigration  Commission). 

This  lack  of  uniformity  in  the  methods  of  study  by  the  three  in- 
vestigators has,  at  least,  one  value.  The  different  standpoints  repre- 
sented by  Warner,  by  Devine,  and  by  the  Immigration  Commission 
suggest  the  desirability  of  determining  approximately  the  extent  of  sick- 
ness as  a  causative  factor  in  poverty  (Warner)  ;  of  recognizing  that  in 
any  given  case  of  dependency  or  of  poverty  that  sickness  may  be  one  of 
a  combination  of  causes  (Immigration  Commission)  ;  and  of  discovering 
and  of  dealing  with  sickness  as  a  problem  in  itself  as  a  condition  accom- 
panying poverty  and  dependency,  whether  it  be  as  cause,  resultant,  or 
coincidence. 

From  the  standpoint  of  the  Commission  there  are,  however,  serious 
limitations  common  to  all  three  studies.  Conditions  have  changed  since 
they  were  made.  The  investigations  are  now  all  out-of-date;  Warner's 
study  was  made  in  the  early  nineties  and  those  of  Devine  and  the  Immi- 
gration Commission  ten  years  ago.     Then,  too,  their  findings  are  not 


*  256 

necessarily  applicable  to  Illinois  and  Chicago.  Devine's  studies  were 
limited  to  New  York.  Chicago  was  not  included  in  the  cities  covered 
by  the  survey  of  dependency  made  by  Warner.  While  Chicago  was  one  of 
the  43  cities  selected  by  the  Immigration  Commission  for  its  study  of 
"Immigrants  as  Charity  Seekers,"  the  data  obtained  now  have  but  limited 
bearing  upon  our  problem.  Moreover,  all  these  studies  stop  at  the  point 
where  the  significant  analysis  of  the  relation  of  sickness  to  the  problem 
of  poverty  and  dependency  should  begin.  They  do  not  analyze  the  nature 
and  extent  of  the  economic  loss  due  to  the  different  types  of  physical 
disability  in  correlation  with  the  facts  ascertainable  concerning  the  eco- 
nomic status  and  standard  of  living  of  the  family.  Finally,  the  findings 
of  these  studies  cannot  be  generalized  to  exhibit  the  relation  of  physical 
.disability  to  poverty  because  they  are  all  confined  to  the  narrow  area  of 
dependency.  It  is  unfortuate  that  for  the  United  States^*  we  have  no 
statistical  evidence  of  the  extent  to  which  sickness  enters  as  a  cause  into 
the  condition  of  poverty. 

Because  of  these  reasons  the  Commission  made  a  study  of  the  data 
furnished  it  by  the  charity  organization  societies  of  eight  Illinois  cities 
outside  of  Chicago  and  of  the  reports  and  records  for  Chicago  of  the 
United  Charities,  the  Associated  Jewish  Societies,  and  of  the  Cook 
County  Agent,  and  made  a  further  analysis  of  the  data  secured  in  its 
Family  Study  from  628  charity  families  and  from  2,708  wage-earning 
families  bearing  upon  the  relation  of  sickness  not  only  to  dependency 
but  also  to  lowered  economic  status,  to  depressed  standards  of  living  and 
to  poverty. 

(2)  SicJcness  as  a  Cause  of  Dependency:  the  Experience  of  Eight  Illi- 
nois Cities. 

Questionnaires  were  sent  out  by  the  Commission  to  superintendents 
of  the  charity  organization  societies  in  Illinois  cities.  Thirteen  replies 
were  received.  Of  these,  the  returns  from  eight  cities  were  in  form 
available  for  tabulation.  Table  25  gives  the  findings  of  the  study  setting 
forth  the  assigned  causes  for  dependency  of  1,464  families  in  these  cities 
of  the  State:  Blue  Island,  Champaign  and  Urbana,  Kankakee,  Kewanee, 
Pekin,   Quincy,  Rockford  and   Springfield. 

A  comparison  of  the  figures  from  the  different  cities  indicates  at 
once  that  the  returns  are  not  altogether  uniform.  Undoubtedly  the 
factor  of  the  personal  equation  in  assigning  causes  of  distress,  and 
probably  also,  differences  in  the  methods  of  record-keeping  are  as  much 
responsible  as  diversities  in  local  conditions,  for  the  different  results. 
Giving  due  weight  to  this  fact,  certain  tentative  conclusions  may  be 
ventured : 

1.  Physical  and  mental  disability  is  assigned  as  a  cause  of  depend- 
ency in  50.8  per  cent  and  as  the  chief  cause  of  dependency  (excluding 
for  this  purpose  the  case  where  "other  illness  is  a  contributory  cause") 
in  38.8  per  cent  of  all  the  families  reported. 

2.  Physical  and  mental  disability,  excluding  injury  from  accident, 
is  assigned  as  a  cause  of  dependency  in  45.7  per  cent,  and  as  the  chief 

^*For  Engrland,  there  are  the  studies  by  Charles  Booth  and  by  Seebohm  Rown- 
tree.  See  Booth.  Life  and  Labour  of  the  People  of  London,  Pauperism  and  the 
Endowment  of  Age,  etc.     Rowntree,  Poverty:     A  Study  of  Town  Life. 


257 


TABLE  25— CAUSES  OF  DISTRESS  IN  DEPENDENT  FAMILIES  FOR  THE 
YEAR  1917-18  FOR  ILLINOIS  CITIES  OUTSIDE  OF  CHICAGO  (AS  RE- 
PORTED  BY   CHARITY   ORGANIZATION   SOCIETIES.) 


• 

•6 
o 

ft 
« 

•1— 1 

•t-t 

0 

O 

a 

c! 

■s 

Number  of  families  where  physical  or  mental  disa- 
bility is  the  assigned  cause  of  distress. 

-a 

fl 

s> 

03 
O 

tiysical 
Id  age. 

Physical  disability  other  than 
accident. 

03 

CO 

03 
§ 

Total  physical  and  mental 
disability. 

Cities  outside  of  Chicago 
reporting  in  full. 

1 

3 
EH 

Chronic  diseases 
other  than 
tuberculosis. 

Other 
illnesses. 

"3 

O  03 

C/3  .^^ 

m 

Sole  or  most 
important 
cause. 

O 

5« 

Blue  Island 

437 

98 

65 

31 

52 

132 

223 

426 

57 

11 

3 

5 

4 

5 

37 

43 

107 

11 

2 

12 

8 

7 

13 

21 

30 
10 
4 
5 
16 
14 
26 

94 

23 

9 

2 

'""'24 
24 

258 
75 
24 
21 
19 
28 
88 

114 

5 
3 
5 
2 
1 
7 
6 
13 

28 
8 
9 

9 

20 

291 
86 
38 
23 
20 
35 
103 
147 

6 

12 

20 

5 

2 

8 

15 

19 

140 

Champaign  and  Urbana 

Kankakee 

7 

Kewanee 

3 

Pekin 

30 

Quincy 

89 

Rockford 

105 

Springfield 

260 

Total 

1,464 
100.0 

165 
11.3 

181 
12.3 

105 
7.2 

176 
12.0 

627 

42.8 

42 
2.9 

74 
5.1 

743 
50.8 

87 
5.9 

634 

Per  cent 

43.3 

—17  H  I 


258 


cause  of  dependency  (excluding  again  the  cases  where  "other  illness  is 
a  contributory  cause'')  in  33.7  per  cent  of  all  the  families  reported. 

3.  Physical  disability,  excluding  injury  from  accident,  is  assigned 
as  a  cause  of  dependency  in  42.8  per  cent,  and  as  the  chief  cause  of  de- 
pendency (excluding  again  the  cases  where  "other  illness  is  a  contribu- 
tory cause")  in  30.8  per  cent  of  all  the  families  reported. 

4.  In  the  group  of  physical  disability  other  than  injury  from  acci- 
dent as  the  assigned  cause  of  dependency,  chronic  disease  other  than 
tuberculosis  is  reported  for  181  cases;  acute  illness  as  a  contributing 
cause  for  176  families;  tuberculosis  for  165  families  and  acute  illness  as 
the  sole  or  most  important  factor  in  105  families. 

As  stated  'in  the  introduction  to  this  study,  all  findings^  for  the 
year  1917-18  must  be  interpreted  with  reference  to  its  unusual  economic 
conditions.  For  example,  the  studies  referred  to  in  the  literature  are 
in  general  agreement  that  one-fourth  of  all  the  causes  or  conditions 
of  dependency  are  attributable  to  physical  and  mental  disability  other 
than  injury  from  accident;  the  Illinois  study  reports  physical  and  men- 
tal disability  other  than  injury  from  accident  as  the  chief  cause  of 
dependency  in  one-third  of  all. cases.  The  larger  proportion  shown  in 
this  study  is  probably  due  not  so  much  to  local  variations  in  Illinois  as 
to  the  year  of  the  study  and  the  influence  of  other  factors.  Two  infer- 
ences may  perhaps  be  suggested:  (a)  that  economic  prosperity  has  a 
greater  effect  in  reducing  dependency  from  other  causes  than  from 
physical  and  mental  disability,  and  (b)  that  within  the  field  of  disease, 
the  dependency  from  acute  illness  is  more  rapidly  diminished  than  that 
which  results  from  chronic  illnesses  such  as  tuberculosis  and  rheuma- 
tism. These  inferences,  while  probably  not  unfounded,  cannot  be 
accepted  as  fact  upon  the  basis  of  the  statistics  of  dependency  for  one 
year.  In  order  to  determine  as  definitely  as  possible  the  changes  over 
a  period  of  years  in  the  relation  of  sickness  to  dependency,  the  Com- 
mission made  a  study  of  the  annual  reports  and  records  of  three  Chicago 
charitable  agencies,  namely,  the  United  Charities,  the  Cook  County 
x^gent,  and  the  Jewish  Aid  Society. 

(3)  A  Study  of  the  Changes  in  the  Relation  of  Siclcness  to  Dependency 
During  an  Eight  Year  Period  From  the  Data  of  Three  Chicago 
Charitable  Agencies. 

The  eight  charity  years,  1910-1918,  were  selected  by  the  Com- 
mission for  a  study  of  the  changes  in  the  relation  of  sickness  to  depend- 
ency as  shown  by  the  data  in  the  annual  records  and  reports  of  the 
United  Charities,  the  Jewish  Aid  Society,  and  the  Cook  County  Agent. 
The  charity  years  signifies  the  fiscal  and  statistical  year  of  each  organi- 
zation. The  charity  year  for  the  United  Charities  is  from  October  1  to 
September  30;  for  the  Cook  County  Agent,  December  1  to  November 
30;  and  for  the  Jewish  Aid  Society,  May  1  to  April  30.  Because  of 
radical  changes  in  the  method  of  record-keeping,  introduced  independently 
by  each  organization  during  1909  and  1910,  it  was  decided  that  it  was 
impracticable  to  begin  the  study  earlier  than  the  charity  year  1910- 
1911.     Table  26  presents  by  charity  year  for  the  three  relief  organiza- 


259 


TABLE  26 — CHANGES  IN  THE  RELATION  OF  SICXNESS  AS  A  CAUSE  OR 
PROBLEM  OF  DEPENDENCY  (AS  SHOWN  BY  THE  RATIO  OF  PHYSI- 
CAL AND  MENTAL  DISABILITY  AS  A  CAUSE  OR  PROBLEM  TO  ALL 
OF  THE  CAUSES  OR  PROBLEMS  OF  DEPENDENCY  FOR  THREE  CHI- 
CAGO CHARITABLE  AGENCIES  FOR  EIGHT  CHARITY  YEARS,   1910-18.) 


Charity  year. 


1910-11 . 
1911-12. 
1912-13. 
1913-14. 
1914-15. 
1915-16. 
1916-17. 
1917-18. 


Total  number  of 

"problems"  (U.  C.) 

or  ''chief  causes" 

(C.  C.  A.  and 

J.  A.  S.)of 

dependency. 


el 
o  =3 


-4-> 

o 


Total  number  of 
cases  where  phy- 
sical and  mental 

disabihty  is 
assigned  as  prob- 
lem or  chief  cause 
of  dependency. 


14,215 
18,983 
16, 246 
21,932 
32,060 
18,614 
13,601 
12,041 


1910-18 147,692 


10,654 

12,635 

9,487 

11,867 

17,253 

9,356 

8,527 

6,714 


86, 493 


>> 

*^ 

p. 

o  • 

o-S 

o  «* 

O 

1 

wo 


Physical  and 

mental  disability 

per  cent  of  total 

number  of 

problems  or  chief 

causes. 


<0 


o  '^ 

o 


1-1 


2, 136 
2, 362' 
2,113i 
3,056 
4,034 
2,688 
1,937 
1,715; 


6,552 
8,195 
7,674 
7,743 
8,717 
8,066 
6,705 
5,647 


20,04159,299 


Unemployment 
per  cent  of  total 

number  of 

problems  or  chief 

causes. 


wO 


>» 

4^ 

^ 

s 

5? 

o  * 

C  o 

U* 

O 

2,276 

830 

46.1 

21.4 

38.8 

17.5 

2,408 

785 

43,2 

19.1 

33.2 

20.3 

2,363 

884 

47.2 

24.9 

41.8 

11.8 

2,133 

985 

35.3 

18.0 

32.2 

28.8 

2,289 

1,232 

27.2 

13.2 

30.6 

40.9 

2,862 

896 

43.3 

30.6 

33.3 

18.2 

3,327 

886 

49.3 

39.0 

45.7 

8.1 

2,475 

812 

46.8 

36.9 

47.3 

6.3 

20, 133 

7,310 

40.2 

23.3 

36.5 

22.3 

21.7 

29.5 

18 

38 

51, 

21, 
5.7 
4.7 


27.8 


16.7 
25.4 
17.0 
35.1 
44.1 
30.8 
10.3 
10.4 


26.8 


260 

tions,  (a)  the  total  number  of  families  cared  for,  (b)  the  number  of 
families  where  physical  and  mental  disability  was  a  "chief  cause"  or 
"problem''  of  dependency,  (c)  the  ratio  of  the  cases  where  physical 
and  mental  disability  was  a  cause  or  problem  to  the  sum  total  of  causes 
and  problems  of  dependency,  and  (d)  the  percentage  of  the  cases  where 
unemployment  was  a  cause  or  problem. 

In  analyzing  the  figures  in  this  table  certain  points  in  regard  to 
the  record-keeping  of  the  different  organizations  should  be  clearly 
understood. 

(a)  The  difference  in  the  months  covered  by  the  charity  year  is 
not  serious  for  our  purpose,  since  the  six  months  from  October  to  April 
provide  the  great  body  of  applications  for  relief. 

(b)  The  three  charitable  agencies  are  not  uniform  in  their  inter- 
pretation of  sickness  or  other  conditions  as  related  to  dependency.  The 
United  Charities  considers  sickness  and  other  conditions  not  as  "causes'' 
but  as  "problems"  connected  with  dependency.  Therefore,  the  total 
number  of  the  "problems"  entering  into  dependency  is,  as  indicated  by 
the  table,  somewhat  larger  than  the  total  number  of  cases  cared  for. 
The  Cook  County  Agent  and  the  Jewish  Aid  Society  assign  sickness 
and  other  conditions  as  the  "chief  cause"  of  dependency.  The  "chief 
cause"  as  given  by  the  Cook  County  Agent  is  the  one  assigned  at  the 
beginning,  as  given  by  the  Jewish  Aid  Society,  the  one  assigned  at 
the  end  of  the  statistical  year.  It  should  be  noted  here  that  for  the  two 
charity  years  1910-12,  the  Jewish  Aid  Society  reported  as  the  "chief 
causes"  the  causes  assigned  at  the  beginning  of  the  year  together  with 
causes  of  dependency  as  they  changed  during  the  year.  Because  of  this 
lack  of  uniformity  in  the  record-keeping  of  the  different  agencies,  a 
basis  of  comparison  is  found  in  the  ratio  of  sickness  as  a  "problem"  or 
"chief  cause"  to  all  the  assigned  "problems"  or  "chief  causes"  of  de- 
pendency. 

(c)  In  the  classification  of  conditions  assigned  as  "causes"  or 
"problems"  of  dependency  there  are,  as  would  be  expected,  certain  varia- 
tions in  the  practice  of  the  agencies.  In  general,  however,  the  system 
of  case-counting  is  quite  uniform.  In  only  two  instances  is  the  diverg- 
ence great  enough  to  be  taken  into  account  in  the  comparative  use  of  the 
figures.  Since  the  United  Charities  is  the  only  one  of  the  three  agencies 
to  enter  "maternity"  as  a  condition  of  dependency,  it  was  excluded  in 
arriving  at  the  sum  total  of  cases  where  physical  and  mental  disability 
was  assigned  as  a  "problem"  of  dependency.  Inasmuch  as  maternity  is 
reported  during  the  period  of  the  eight  charity  years,  as  a  problem  in 
about  one-tenth  of  the  total  number  of  problems,  its  inclusion  as  sickness 
would  add  an  absolute  10  per  cent  to  the  percentage  of  physical  and  mental 
disability  as  a  factor  entering  into  dependency.  Much  more  difficult  from 
the  standpoints  of  classification  is  the  wide  difference  in  the  inter- 
pretation of  "insufficient  earnings"  as  a  condition  of  dependency.  With 
the  United  Charities  ascribing  only  4  to  6  per  cent,  the  Jewish  Aid 
Society  10  to  20  per  cent  and  the  Cook  County  Agent  uniformly  25  per 
cent  of  the  total  of  conditions  and  causes  of  poverty  to  "insufficient  earn- 
mgs,"  it  is  obvious  that  the  relative  ratios  assigned  to  other  factors  must 
be  correspondingly  affected.    The  low  proportion  of  cases  in  the  United 


261 

Charities  where  "insufficient  earnings"  is  reported  as  a  problem  is  due 
to  its  strict  construction  of  the  term.  The  chief  statistician  informed 
the  investigator  for  the  Commission  that  cases  were  assigned  to  this 
cause  only  where  earnings  were  markedly  below  the  current  rate  of  wages 
or  where  the  size  of  the  family  was  larger  than  could  be  supported  by  the 
existing  wage-scale ;  in  all  other  cases  the  underlying  cause  of  insufficient 
earnings  was  determined  and  the  case  counted  under  that  condition.  The 
high  pioportion  of  cases  ascribed  by  the  Cook  County  Agent  to  "insuffi- 
cient earnings''  is,  on  the  other  hand,  undoubtedly  due  to  a  liberal  con- 
struction of  the  term.  Investigators  for  the  Commission  in  reading  over 
one  hundred  of  the  original  records  of  cases  applying  to  the  County  Agent 
for  relief  came  to  the  conclusion  that  the  phrase  "insufficient  earnings" 
was  employed  as  an  omnibus  term,  including  conditions  not  only  where 
earnings  were  below  the  current  standard,  or  inadequate  for  families  of 
large  size,  but  also  where  physical  disabilities  of  various  types  or  personal 
and  moral  deficiencies  or  other  factors  lay  back  of  the  assigned  cause. 
Although  there  was  no  feasible  basis  for  the  correction  of  this  difference 
in  classification,  it  is  apparent  why  the  percentages  of  physical  and 
mental  disability  for  the  Cook  County  Agent  are  lower  than  for  the 
United  Charities  or  for  the  Jewish  Aid  Society. 

(d)  The  validity  of  the  procedure  of  assigning  causes,  and  par- 
ticularly chief  causes,  of  dependency  and  poverty  has  been  called  into 
question.  One  of  the  objections  raised  is  that  since  the  assignment  of 
cause  is  worth  no  more  than  the  opinion  of  the  person  making  it,  (par- 
ticularly in  the  field  of  poverty  and  dependency)  the  factor  of  the  per- 
sonal equation  will  render  unreliable  the  data  secured  in  this  way.  A 
second  criticism  is  that  inexperienced  social  workers  are  prone  to  report 
too  often  the  apparent  cause  of  dependency  which  in  most  cases,  is  not 
the  fundamental  cause.  A  third,  and  probably  the  most  cogent,  stricture 
is  that  the  cause  of  poverty  and  dependency  are  complex  and  that  any 
attempt  to  assign  a  chief  cause  is  futile.  While  much  may  be  said  in 
support  of  all  three  of  these  objections,  it  is  in  point  to  state  that  they 
apply  probably  with  less  force  to  sickness  than  to  the  other  conditions 
or  causes  of  dependency.  The  development  of  medical  service  in  connec- 
tion with  the  work  of  the  charities  has  made  the  report  of  the  diagnosis 
of  disease  and  of  the  physical  examination  by  the  physician  an  indispens- 
able part  of  the  records.  Then,  too,  the  elevation  of  standards  and  the 
rapid  trend  toward  the  professionalization  of  social  work  has  removed 
much  of  the  forces  of  the  objections  stated  above. 

With  this  background  for  understanding  the  nature  and  differences 
in  the  record-keeping  of  the  three  charitable  agencies,  certain  generaliz- 
ations may  be  suggested  from  the  data  presented  in  the  table : 

(a)  Increases  or  decreases  in  the  total  number  of  families  or  cases 
aided  from  year  to  year  are  invariably  uniform  for  all  three  charitable 
agencies.  This  indicates  that  the  pressure  of  poverty  impinges  with  rela- 
tively equal  force  upon  the  relief-giving  agencies  of  Chicago. 

(b)  The  absolute  number  of  cases  where  physical  or  mental  dis- 
ability is  a  condition  or  cause  of  dependency  rises  or  falls  in  most  but 
not  all  instances  with  the  increase  or  decrease  in  the  total  number  of 
cases  aided.  This  rise  and  fall  is  absolute  and  not  proportionate  to  the 
changes  in  the  entire  group  of  dependents. 


2(j2 

(c)  The  percentage  of  problems  or  chief  causes  where  physical  or 
mental  disability  is  a  problem  or  chief  cause  is  relatively  uniform  for  the 
United  Charities  and  for  the  Jewish  Aid  Society^  except  for  the  year 
1914-15.  For  the  eight  year  period  the  proportion  of  problem  where 
sickness  was  a  condition  ranged  for  the  United  Charities  (excluding 
1914-15)  from  35.3  to  49.3  per  cent;  for  the  Jewish  Aid  Society  (not 
excluding  1914-15)  from  30.6  to  47.3  per  cent;  and  for  the  Cook 
County  Agent  (excluding  1914-15)  from  18.0  to  39.0  per  cent.  For  the 
last  three  years  (1915-18)  the  Chicago  charities  have  reported  sickness 
as  a  cause  or  problem  of -poverty  in  from  30  to  50  per  cent  of  the  causes 
or  problems  assigned  for  dependency. 

(d)  The  unusually  large  degree  of  unemployment  in  the  year  1914- 
15  exhibits  its  effect  in  an  unprecedented  increase  in  dependency.  With 
all  three  organizations  the  absolute  nmnber  of  cases  where  sickness  is  a 
problem  also  rises  but  the  proportion  of  cases  where  sickness  is  a  problem 
or  a  cause  declines  sharply.  This  is  the  natural  resultant  of  the  con- 
junction of  sickness  as  the  most  constant  and  unemployment  as  the  most 
variable  cause  of  dependency. 

(e)  The  great  reduction  in  dependency  from  unemployment  in  the 
two  charity  years  1916-18  has  been  accompanied  by  an  absolute  decrease 
in  the  number  and  by  an  increase  in  the  proportion  of  causes  or  problems 
ascribed  to  sickness. 

(f)  In  general  the  percentage  of  problems  or  causes  of  dependency 
where  sickness  is  a  cause  or  a  problem  varies  inversely  with  the  total 
number  of  causes  or  problems.  It  is  perhaps  fair  also  to  state  that, 
aside  from  years  of  unemployment,  the  proportion  of  all  the  causes  or 
problems  of  dependency  assigned  to  sickness  by  Chicago  charitable 
agencies  ranges  from  one-third  to  one-half  of  the  total  number  of  causes 
or  problems  of  dependency. 

The  high  ratio  of  sickness  as  a  cause  or  condition  of  poverty  in  the 
experience  of  Chicago^s  charitable  agencies  requires  further  analysis. 
The  studies  of  Warner,  of  D'evine,  and  of  the  Immigration  Commission, 
as  we  have  seen,  correspond  closely  in  designating  sickness  as  the  cause 
or  a  condition  of  dependency  in  one-fourth  as  compared  with  the  reports 
and  records  of  Chicago's  charities  which  assign  to  sickness  one-third  to 
one-half  of  all  the  causes  and  conditions  of  dependency.  The  explan- 
ation is  not  difficult.  Interest  in  the  study  of  dependency  is  at  its  height 
when  the  problem  of  poverty  is  acute.  Fluctuations  of  the  poverty  cycle 
naturally  follow  its  most  variant  factor,  im employment.  With  wide- 
spread unemployment,  the  circle  of  poverty  rapidly  expands,  thousands 
of  families  are  pushed  below  the  level  of  bare  subsistence,  and  dependency 
reaches  its  maximum.  Warner,  Devine,  and  the  Immigration  Com- 
mission all  made  their  studies  in  periods  of  unemployment.  The  factor 
of  unemployment  is  reported  in  29.6  per  cent  of  Warner's  7,225  cases  ;^^ 
in  69.2  per  cent  of  Devine's  5,000  families;^®  in  76.4  per  cent  of  Devine's 
1,000  families,^^  and  in  43.2  per  cent  of  the  31,374  cases  reported  by  the 
Immigration  Commissi on.^^     Only  in  the  year   1914-15,  long-to-be-re- 


35  Warner,  op.  cit.  p.   55. 
8«Op.  cit.  p.   204. 
»^  Op.  cit.  p.  228. 
»8  0p.  cit.  p.   120-1. 


263 

membered  in  Chicago  for  an  unprecedented  volume  of  unemployment, 
is  the  percentage  of  43.2  per  cent  of  the  Immigration  Commission  sur- 
passed and  then  only  by  two  of  the  three  Chicago  charitable  agencies. 
The  percentages  of  unemployment  reported  by  Devine,  69.2  per  cent 
and  76.4  per  cent,  are  never  attained.  The  nearest  approach  to  his  ratio 
is  the  59.4  per  cent  of  unemployment  found  in  the  22,105  cases,^^  aided 
by  the  United  Charities  in  1914-15.  Even  the  relatively  moderate  ratio 
of  unemploment,  29.6  per  cent,  reported  by  Warner  is  exceeded  outside 
of  the  unemployment  years  1913-15  in  only  one  year  by  one  organization. 

The  conclusion  seems  unescapable  that  the  periods  of  the  investi- 
gations by  Warner,  Devine,  and  the  Immigration  Commission  are  ab- 
normal for  the  study  of  poverty.  The  unusual  volume  of  relief  from 
charity  due  to  the  variable  factor  of  unemployment  occasioned  a  corres- 
ponding drop  in  the  proportion  of  the  more  constant  causes  of  de- 
pendency. We,  therefore,  conclude  that  the  period  of  eight  years  covered 
by  this  study  more  accurately  reflects  normal  and  usual  conditions,  than 
the  one-year  and  two-year  periods  selected  by  earlier  investigators. 
There  need,  then,  be  no  hesitation  on  grounds  of  divergencies  from 
previous  investigation  in  accepting  the  report  of  Chicago's  charitable 
agencies,  that  outside  of  years  of  unemployment,  sickness  is  assigned  as 
a  chief  cause  or  a  serious  problem  in  one-third  to  one-half  of  all  the 
apparent  causes  and  problems  of  dependency. 

The  records  and  reports  of  the  United  Charities  and  the  Cook 
County  Agent  made  it  possible  for  the  Commission  to  isolate  and  com- 
pare the  relation  to  dependency  of  the  three  types  of  physical  disability 
(excluding  injury  from  accident)  :  namely,  tuberculosis,  chronic  dis- 
eases other  than  tuberculosis,  and  acute  illness.  Apparently  only  the 
two  following  conclusions  may  be  drawn  from  Table  27  which  exhibits 
the  number  and  proportion  of  these  three  groups  of  physical  disabilities 
by  charity  years : 

(1)  In  reporting  the  distribution  of  physical  disabilities  other  than 
those  arising  from  accident  as  a  serious  problem,  the  United  Charities 
assigned  roughly,  one-half  to  acute  illnesses,  one-fourth  to  tuberculosis 
and  one-fourth  to  chronic  diseases  other  than  tuberculosis;  and  the  Cook 
County  Agent  attributed  about  three-fifths  to  acute  illnesses ;  one-fifth 
to  tuberculosis,  and  one-fifth  to  chronic  diseases  other  than  tuberculosis. 

(2)  The  absolute  number  of  cases  classified  imder  the  three  types 
of  sickness  rise  with  the  increase  in  unemployment  and  fall  with  the  re- 
turn to  normal  working  conditions  apparently  with  no  consistent  vari- 
ations between  the  different  sickness  groups.  An  illustration  will  sug- 
gest the  way  in  which  the  alternation  of  opposite  factors  will  have  no 
effect  upon  the  ratio  of  dependency  attributed  to  the  disease.  In  times 
of  economic  stress,  such  as  unemployment,  the  proportion  of  dependency 
caused  by  tuberculosis  tends  to  rise;  when  normal  conditions  of  in- 
dustrial life  are  restored,  the  ratio  of  the  tuberculous  reported  by  chari- 
table agencies  tends  to  be  maintained  or  even  increased  because  of  the 
chronic  nature  of  the  ailment. 

"  This  percentage  is  obtained,  as  stated,  on  the  basis  of  the  number  of  cases 
aided,  not  of  the  total  of  "problems"  assigned.  Note  difference  from  percentage  of 
unemployment  reported  in  Table  26. 


264 


TABLE  27 — NUMBER  AND  PROPORTION  OP  THE  THREE  TYPES  OF  PHYSI- 
CAL DISABILITY  (EXCLUDING  INJURY  FROM  ACCIDENTS)  BY 
CHARITY  YEARS  AS  REPORTED  BY  THE  UNITED  CHARITY  AND  COOK 
COUNTY  AGENT,    1910-18. 


Charity  year. 


Number  of  eases  where  physical  disability 

(excluding  accident)  is  assigned  as  problem  or  chief 

cause  of  dependency. 


Total 
number. 


Is 
•a-s 


o  <^ 


Tubercu- 
losis. 


o 

•a-s 


o    * 

o  <* 
O 


Chronic 

diseases 

other 

than  tuber- 

culosis. 

>> 

^ 

*» 

M 

a 

<D 

a 

"3  M) 

C  o 

O  «3 

P 

o 

Acute 
illness. 


®  is 

0 


3 


Per  cent  of  cases  of  phy- 
sical disability  (exclud- 
ing accident). 


Tuber- 
culosis. 


bjO 


© 

©  is 
fl  © 


3 


Chronic 
other 
than 
tuber- 
culosis. 


2^  ©  _ 


2a 


o 
O 


c  © 

p 


3 

_v   © 

o  =s 
O 


Acute 
illness. 


3 

3 

M    © 

o  « 
O 


1910-11.... 
1911-12.... 
1912-13.... 
1913-14.... 

1914-15 

1915-16.... 
1916-17. . . . 
1917-18.-.. 

1910-18 


5,619 

1,945 

1,161 

248 

1,828 

466 

2,630 

1,231 

20.7 

12.7 

32.5 

23.9 

46.8 

7,038 

2,052 

1,317 

252 

1,561 

726 

4,160 

1,074 

18.7 

12.3 

22.2 

35.4 

59.1 

6,581 

2,031 

1,494 

315 

1,491 

443 

3,596 

1,273 

22.7 

15.5 

22.7 

21.8 

54.6 

6,654 

1,862 

1,584 

447 

1,456 

502 

3,614 

913 

23.8 

24.0 

21.9 

27.0 

54.3 

7,547 

2,019 

1,885 

487 

1,644 

475 

4,018 

1,057 

25.0 

24.1 

21.8 

23.5 

53.2 

7,191 

2,525 

1,829 

476 

1,657 

482 

3,705 

1,567 

25.4 

18.8 

23.0 

19.1 

51.6 

6,007 

2,903 

1,474 

508 

1,191 

489 

3,342 

1,906 

24.5 

17.5 

19.8 

16.8 

5.5.6 

4,931 

2,163 

1,431 

480 

1,084 

386 

2,416 

1,297:29.0 

22.2 

22.0 

17.8 

49.0 

51,568 

17,500 

12, 175 

3,213 

11,912 

3,969 

27,481 

10,318 

23.6 

18.4 

23.1 

22.7 

53.3 

63.4 
.52.3 
62.7 
49.0 


52. 
62. 
65. 


60  0 
59.0 


265 

In  resume,  the  three  important  findings  of  this  study  of  the  eight 
years'  experience  of  three  charitable  agencies  may  be  restated:  (a)  that 
sickness  is  designated  as  a  cause  or  condition  in  one-third  to  one-half 
of  the  sum  total  of  causes  and  conditions  assigned  to  dependency;  (b) 
that  regular  employment  and  increased  wages  decreases  the  number  but 
not  the  ratio  of  cases  in  which  sickness  is  assigned  as  a  cause  of  de- 
pendency; and  (c)  that  the  proportion  of  dependency  attributed  to  the 
cliffeient  types  of  sickness  sustains  a  relatively  constant  ratio  of  50  to  60 
per  cent  for  acute  illnesses  to  40  to  50  per  cent  for  chronic  diseases  in- 
cluding tuberculosis.  The  bearing  of  these  conclusions  upon  the  problem 
of  the  extent  of  dependency  is  obvious. 

The  value  of  these  results,  while  real,  is  limited.  They  locate  but 
do  not  attack  the  salient  issues  of  the  problem.  The  service  of  statistics 
and  case-counting  stop,  of  course,  at  this  point.  The  method  of  case- 
study  is  necessary  if  the  analysis  is  to  be  pushed  farther. 

(4)  SicJcness  as  a  Factor  in  the  Process  of  Economic  Degradation  from 
a  Case  Study  of  OB'S  Oha^-ity  Families. 
The  statistical  studies  of  sickness  do  not  go  behind  the  assigned 
causes  and  conditions  of  dependency.  The  investigations  already  dis- 
cussed, made  both  by  the  Commission  and  by  others,  do  not  indicate  the 
nature  of  the  part  which  sickness  plays  in  the  process  of  economic  degra- 
dation. Nor  do  they  give  evidence  of  the  interrelation  with  sickness  of 
other  factors  making  for  poverty  and  dependency.  In  order  to  attack 
these  problems  a  case-study  was  made  of  the  628  charity  families  in  the 
Family  Study.  Considerations  favorable  to  the  selection  of  this  group 
for  further  intensive  study  are  as  follows: 

(a)  The  628  families  were  assigned  by  the  United  Charities  and 
Jewish  Aid  Society  as  cases  where  sickness  was  a  cause  or  a  condition  of 
dependency.  They  should,  therefore,  be  fairly  representative  of  desti- 
tution in  Chicago  where  sickness  is  present  as  part  of  the  problem,  ex- 
cept in  one  respect,  viz.  the  relative  numbers  of  those  with  chronic  and 
acute  illnesses. 

(b)  The  schedule  used  in  the  study  provided  not  only  a  wealth  of 
information  upon  social,  medical  and  economic  aspects  of  family  life,  but 
in  practically  all  cases  contained  a  narrative,  the  so-called  '^^story,"  cover- 
ing points  of  special  significance. 

(c)  The  data  were  regarded  as  unusually  reliable  since,  as  stated 
earlier  in  this  report,  they  were  secured  for  the  628  charity  families  not 
only  by  a  visit  to  the  home  but  also  by  a  prior  consultation  of  quite  com- 
plete charity  records  extending  over  a  period,  in  practically  all  cases,  of 
months  and,  in  many  instances,  of  years. 

The  findings  from  the  study  of  the  628  charity  families  fall  under 
the  three  following  heads : 

(a)  The  chief  forms  of  sickness  as  factors  in  the  process  of  eco- 
nomic degradation. 

(b)  Variations  in  the  ratio  of  those  dependent  because  of  sickness 
according  to  the  prior  economic  condition  of  the  family. 

(c)  Largeness  of  family  interrelated  with  sickness  in  causing  de- 
pendency. 


266 


(a)  The  Chief  Forms  of  Sickness  as  Factors  in  Economic  Degradation. 
In  studying  the  relation  of  sickness  to  poverty,  it  was  realized  that 
there  is  no  one  sickness  problem,  but  rather  the  problems  of  many  sick- 
nesses. Acute  indigestion,  a  "cold/'  a  sprained  ankle,  pneumonia,  rheu- 
matism, tuberculosis,  involve  quite  different  economic  losses.  It  seemed 
in  point  therefore  to  determine  for  each  charity  case  selected  because  of 
the  presence  of  the  problem  of  sickness,  the  predominant  cause  of  poverty. 
It  was  apparent  at  once  that  the  628  families  fall  into  two  groups : 

1.  Disrupted  families :  those  without  adult  male  wage-earner. 

2.  Families  not  disrupted:  those  with  adult  male  wage-earner. 
The   major   cause   of   dependency   in   the   disrupted   families   was 

assigned  either  directly  or  indirectly  to  the  absence  of  the  adult  wage- 
earner.  The  following  table  exhibits  by  nationality  the  relative  pro- 
portion of  the  628  charity  families  studied  where  the  broken  home  must 
be  regarded  as  the  principal  cause  of  dependency. 


Number 

of 
families. 

Families  disrupted. 

Families  not 
disrupted. 

Nationality. 

By  death  of  adult 
male  wage  earner. 

deser- 
tion. 

Total  disrupted. 

Number. 

Before 

year 

of  study. 

During 

year 
of  study. 

Number. 

Per  cent. 

Percen  . 

United  States,  white 
United  States,  black 
Bohemian 

1 

115 
23 
15 
69 
46 
79 
39 
8 

126 
27 
81 

5 
1 
2 
11 
6 
7 
1 

11 
1 

8 
2 

24 
4 
2 

19 
8 

12 
1 

20.9 
17.4 
13.3 
27.5 
17.4 
15.2 
2.6 

91 
19 
13 
50 
38 
67 
38 
8 
107 
18 
62 

78.1 
82.6 
86.7 

German 

2 
2 
2 

6 
3" 

72.5 

Irish 

82.6 

Italian 

84.8 

Jewish 

97.4 

Lithuanian 

■ 

100.0 

Polish 

12 

4 
6 

3 

1 
3 

4 

4 

10 

19 

9 

19 

15.1 
33.3 
23.5 

84.9 

Scandinavian 

Other 

66.7 
76.5 

Total 

628 

55 

25 

37 

117 

18.6 

511 

81.4 

Disrupted  families. — This  table  indicates  that  in  117  or  in  18.6  per 
cent  of  the  628  families  the  economic  degradation  of  the  family  was  due, 
directly  or  indirectly,  to  the  death  or  the  desertion*^  of  the  normal 
breadwinner.  In  those  cases  without  question  death  and  desertion 
rather  than  sickness  are  the  cause  of  the  economic  distress  of  the  family. 
Moreover,  the  records  show  that  the  strain  upon  the  mother  of  double 
work  both  outside  and  inside  the  home  often  results  m  nervous  and 
physical  breakdown  and  lowered  resistance  to  disease.  Where  sickness 
occurs  in  these  disrupted  families  it  does  not  occasion  poverty  but  further 
depresses  an  already  unstable  economic  condition. 

That  sickness,  though  a  condition,  is  not  in  these  families  a  cause 
of  dependency  is  indicated  by  the  history  of  the  following  two  cases  which 
are  fairly  representative  of  the  entire  group. 

*°  It  should  be  stated  that  "cases  of  death  of  wage-earner  during  the  year  of 
the  study,"  as  a  cause  of  dependency,  does  not  include  cases  where  the  family 
appealed  to  charity  for  assistance  during  the  disability  which  was  later  responsible 
for  his  death.  These  cases  are  entered  under  the  appropriate  sickness  or  accident 
causes  of  dependency. 


367 

Case  1.  Normal  breadwinner  dead. — The  father  in  this  Russian 
Polish  family  died  in  1914,  leaving  a  widow  and  three  children  ten, 
nine,  and  six  years  old  dependent  upon  the  public  for  support.     The 
mother  and  children  are  under  treatment  for  glandular  tuberculosis 
at  the  Municipal  Tuberculosis  Sanitarium  but  have  sujffered  from 
no  other  ailments  during  the  year  of  the  study.     The  mother  has,  at 
times,  been  able  to  work  in. restaurants  and  elsewhere,  but  after  a 
few  days  of  employment  gives  up  her  "job."     She  insists  upon  stay- 
ing at  home  and  caring  for  her  children.     She  does  not  want  them 
running  wild  upon  the  street.     She  does  sewing,  therefore,  for  the 
'  neighbors,  but  never  makes  more  than  $2.75  or  $3  a  week,  and 
sometimes  much  less.     During  the  present  year  she  was  unable  to 
sew  for  sixteen  weeks  because  of  eye  trouble  and  her  tubercular  af- 
fection.    Henry,  the  oldest  boy,  now  fourteen  years  old,  has  just 
finished  the  eighth  grade  and  expects  to  go  to  work.^^ 
Here  we  have  a  clear  picture  of  economic  degradation  due  to  the 
death  of  the  father,  where  disease  is  not  the  primary  cause  of  poverty 
and  dependency,  but  rather  the  result  of  it.    Allowances  under  the  Funds 
to  Parents  Law  are  extended  to  hundreds  of  other  families  disrupted  by 
the  death  of  the  father,  but  in  scores  of  cases,  as  in  this  instance,  the 
deceased  husband  was  an  alien  and  the  wife  has  not  had  time  to  secure 
"final  papers"  giving  her  citizenship.    The  mother  with  the  eare  of  three 
children  and  in  spite  of  her  physical  disability  earned  about  $100  during 
the  year ;  the  deficit  was  made  up  by  three  Chicago  charities. 

Case  2.  Normal  breadwinner  a  chronic  deserter. — This  family  is 
com]X)sed  of  husband,  wife  and  six  children  aged  eight  years, 
six  years,  five  years,  four  years,  two  years  and  the  bab}',  three  months 
old.  At  his  present  "job"  as  a  butcher,  the  husband  earns  $2S  a 
week.  The  family  must  periodically  appeal  to  charity  because  of  the 
frequency  with  which  the  father  deserts  his  home — 14  times  in  10 
years.  During  the  past  year  the  mother  was  confined  and  the  chil- 
dren all  had  whooping  cough.  The  wife  is  an  ignorant  sort  of 
woman — sloppy,  unkempt,  who  has  a  slave-like  devotion  to  her  hus- 
band, and  instead  of  having  him  arrested  she  pleads  to  the  judge,  in 
court.  The  children  are  all  dirty.  Even  though  always  at  the  wash- 
tub,  the  mother  never  looks  clean. 

The  type  of  deserter,  whether  occasional,  temporary,  periodic,  or  per- 
manent*^ has  of  course  different  effects  upon  the  economic  statuts  of  the 
family.  For  the  most  part,  however,  these  differences  are  in  degree,  not 
in  type.  The  family  as  a  social  whole  is  disrupted  and  its  economic  as 
well  as  social  status  lowered.  When  sickness  appears,  as  in  this  family 
it  is  not  certainly  a  causative  factor  but  rather  a  condition  or  problem  of 
dependency.  It  is  evident  in  these  disrupted  families  that  the  funda- 
mental cause  of  dependency  is  the  death  or  desertion  of  the  wage-earner 
and  that  sickness  enters  more  as  a  result  than  as  a  cause  in  the  process 
of  economic  degradation. 


*^  In  presenting-  the  cases  in  this  report,  it  has  been  thought  best  to  use  the 
language  of  the  agents  practically  without  change. 

*'  See  Eubank.  E.  E..  A  Study  of  Family  Desertion,  for  an  analysis  of  the  prob- 
lems of  family  desertion  in  Chicago. 


2C)8 


Families  not  disrupted. — Of  the  511  families  not  disrupted  the 
reason  for  dependency  in  8  cases  was  the  old  age  of  the  normal  bread- 
winner— a  problem  clearly  distinct  from  that  of  illness.  The  following 
I'ases  represents  the  tragedy  of  extreme  destitution  in  old  age : 

Case  3.  Old  age. — Mr.  M.  is  71,  his  wife  is  74;  they  are  alone 
in  the  world.  Mr.  M.  has  suffered  from  rheumatism  for  ten  years, 
and  Mrs.  M.  has  been  disabled  from  the  same  affliction  for  15 
years.  This  case  was  reported  to  the  charities  by  a  woman  in 
the  neighborhood  w^ho  saw  Mrs.  M.  searching  garbage  cans  of 
grocery  stores  and  delicatessen  shops  for  food.  They  had  been 
working  as  janitors  of  the  building  in  wdiich  they  live.  For  this 
they  received  $10,  but  paid  $1  rent.  Their  ambition  is  to  save 
enough  money  to  enter  a  home,  as  they  cannot  bear  to  be  separated, 
or  to  enter  a  charitable  institution.  In  January  of  this  year  Mr. 
M.  was  struck  by  a  street  car  and  so  bruised  that  he  could  not  do 
the  janitor  work.  Mr.  M.  is  hoping  to  get  work  elsewhere.  He 
is  a  very  heavy  man,  and  that,  together  with  his  age  and  rheuma- 
tism, prevents  his  doing  active  work.  The  income  of  both  Mr.  and 
Mrs.  M.  last  year  was  only  $62.  The  deficit  was  cared  for  by 
charity. 

Excluding  these  8  families  where  old  age  is  the  primary  cause  of 
dependency  and  disability  is  a  contributory  condition,  the  analvsis  as 
shown  by  Table  28  by  cause  of  dependency  and  by  nationality  was  made 
for  the  remaining  503  families. 

The  outstanding  fact  shown  by  this  table  is  the  large  role  appar- 
ently played  by  tuberculosis  and  other  chronic  diseases  in  the  causation 
of  poverty.  In  38  of  the  503  families  sickness  was  found  not  to  be  a 
cause  of  dependency.*^  The  following  summary  statement  has  been 
prepared  for  the  remaining  465  families  where  sickness  was  assigned 
as  a  cause  of  poverty: 


Cause  of  poverty. 

Families  with  sickness  or 

accident  cause  of 

dependency. 

• 

Number. 

Per  cent. 

Normal  breadwinner  disabled  by — 

Insanity - 

33 
129 
160 
18 
49 
60 
16 

7.1 

Tuberculosis 

27.7 

Chronic  disease  other  than  tuberculosis 

34.4 

Physical  defect 

3.9 

Accident 

10.5 

Acute  illness ■ 

13.0 

Sickness  in  family 

3.4 

-  According  to  this  analysis,  of  all  cases  where  disability  of  normal 
breadwinner  or  members  of  family  was  ascribed  as  major  cause  of 
dependency,  289  or  62.1  per  cent  were  due  to  tuberculosis  and  other 
chronic  diseases. 

Without  endeavoring  to  minimize  the  importance  of  chronic  dis- 
eases as  causal  factors  in  poverty,  recognition  must  be  given  to  the  fact 

*8  In  15  of  these  families  there  was  sickness  in  the  preceding  year  but  not  in 
the  year  of  the  study. 


209 


TABLE  28—503  CHARITY  FAMILIES  NOT  DISRUPTED  BY  DEATH  AND  DE- 
SERTION CLASSIFIED  BY  CAUSES  OF  DEPENDENCY  (EXCLUDING 
OLD   AGE)    AND   BY   NATIONALITY. 


Disability  of 

T3 

Cause  of  dependency  the  disability  of  normal 

normal  breadwin- 

a 

-^j 

breadwinner  by — 

ner  not  a  cause  of 

3 

dependency. 

Chronic 

0 

0 

o 

Tuberculosis. 

disease  other 

Injury  through 

n 

0 

Nativity  or  race  of  head 

C/5 

than 

accid.ent. 

J? 

S!^ 

of  family. 

••H 

tuberculosis. 

>. 

s 

o 

>. 

.i^ 

to 

a 
0  s? 

c 
3  • 

0  S 

c    . 

4^ 

c3 

;3 

3 

CO 

0 

04 

0} 

SS  in  f  am. 
ndency. 

SS  not  a 
ndency. 

B 

^ 

^^ 

3f« 

^  >> 

S5S 

^ 

OT 

s 

0 

0 

0  eo 

a  G, 

* 

c3 

C3 
0 

ta 

0 

>. 

A 

0 

3 

-d 

0.5 

-t.3 
0 

3 

«i3 

^ 

Eh 

:z; 

;^ 

H 

^ 

^ 

Ph 

e 

;z; 

^ 

^ 

CQ 

m 

United  States,  white. . 

89 

6 

22 

6 

16 

22 

6 

16 

3 

7 

6 

1 

13 

5 

11 

United  States,  colored 

19 
13 
49 

'"2 

7 

6 

7 

13 

1 
3 
5 

5 

4 
8 

5 

3 

19 

'"6 

5 

3 

13 

7 

1 

Bohemian 

.... 

1 
4 

1 
1 

German 

3 

1 

1 

3 

Irish 

37 
66 
38 
8 
107 
17 
60 

2 
2 
3 
1 

8 

1 
1 

6 

14 

5 

1 
3 
3 

5 

11 

2 

13 
20 
21 

2 
30 

3 
22 

2 
5 
5 
2 
11 
1 
2 

11 
15 
16 

4 
1 
2 

5 
7 
1 
2 
14 
4 
4 

2 
2 

'"2 
7 
2 

1 
3 

1 

2 
2 

3 
15 
3 
1 
7 
1 
9 

1 
2 

1 

4 

2 

3 

Italian 

5 

Jewish 

2 

Lithuanian 

2 

Polish 

36 

6 

14 

11 
2 

1 

25 

4 

13 

19 

2 

20 

4 
""3 

4 
■"2 

3 
2 
2 

4 

Scandinavian 

2 

Other 

5 

Total 

503 

33 

129 

36 

93 

160 

40    120 

18 

49 

23 

15 

11 

60 

16 

38 

270 

that  the  findings  of  this  study  exaggerate  both  the  actual  and  the  nor- 
mal proportion  of  dependency  due  to  chronic  as  compared  with  acute 
diseases.  This  overstatement  of  the  role  of  chronic  diseases  was  due 
to  two  of  the  conditions  of  the  study., 

1.  The  actual  proportion  of  acute  diseases  is  undoubtedly  higher 
than  indicated  by  the  table.  In  the  first  place,  the  time  of  year,  late 
spring  and  early  summer,  when  the  628  families  were  assigned  by  the 
United  Charities  resulted  in  an  apparent  disproportion  of  chronic 
cases.  As  is  well  known,  the  major  part  of  dependency  from  acute 
illness  occurs  in  the  winter  months.  In  the  second  place,  where  both 
acute  and  chronic  illnesses  were  present  during  the  year,  the  cause  of 
poverty  was  invariably  assigned  to  the  chronic  disability.  In  the  third 
place,  illnesses  of  members  of  the  family  other  than  the  breadwinner, 
while  assigned  as  principal  causes  of  poverty  in  only  16  families,  were 
found  in  a  majority  of  the  other  families  and  contributed  to  an  accentu- 
ation of  the  lowered  economic  condition.  In  this  connection  it  should 
also  be  mentioned  that  the  larger  proportion  of  children's  diseases  are 
acute  rather  than  chronic.  In  the  fourth  place,  acute  illnesses,  especi- 
ally those  without  adequate  medical  treatment,  predispose  the  indi- 
vidual, through  a  lowered  physiological  resistance,  to  chronic  diseases. 
The  difficulty  of  ascertaining  this  indirect  effect  of  acute  sickness  is 
readily  understood. 

2.  The  normal  proportion  of  acute  diseases  as  causes  of  poverty 
is  unquestionably  somewhat  higher  than  for  the  year  of  the  study.^* 
The  unusual  industrial  situation  of  1917-18  must  be  taken  into  con- 
sideration in  the  interpretation  of  the  figures  in  the  table.  The  regu- 
larity of  work,  at  wages  relatively  high,  even  in  comparison  with  the 
increased  cost  of  living,  for  all  able-bodied,  and  indeed  semi-able-bodied 
men,  women  and  older  children,  presents  a  condition  unprecedented  for 
Chicago.  All  the  charitable  agencies  of  the  citv — the  United  Charities, 
the  Jewish  Aid  Society,  the  Cook  County  Agent — report  a  decrease  in 
the  number  of  families  applying  for  and  receiving  aid.  How  would 
this  increased  income  affect  the  distribution  between  chronic  and  acute 
illness  as  a  cause  of  poverty?  The  poverty  caused  by  chronic  sickness 
would  be  only  slightly  if  at  all  reduced,  because  of  the  inability  of  the 
breadwinner  to  work  at  all  for  the  many  weeks  of  his  disability.  On 
the  other  hand  the  few  weeks  lost  by  the  wage-earner  out  of  work  from 
acute  illness  could  be  borne  in  many  more  families  in  1917-18  than 
in  previous  years  without  appeal  to  charitable  assistance. 

In  addition  to  these  facts  it  must  be  noted  that  a  considerable 
number  of  those  in  the  groups  from  which  these  dependents  came  had 
health  insurance.  As  a  rule,  the  benefits  paid  under  it  are  small  sums 
per  week  and  are  usually  limited  to  a  fraction  of  the  year,  ^o  doubt 
it  made  it  possible  for  a  larger  number  of  those  afflicted  with  acute 
temporary  illness  than  of  those  with  chronic  disease  to  get  on  without 
appeal  to  charity. 

The  way  in  which  the  economy  of  family  life  is  actually  affected 
by  the  different  tvpes  of  physical  and  mental  disability  may  best  be 
shown  by  summaries  of  the  histories  of  families  representative  of  the 


44 


For  example,  see  percentages  in  Table  27,  page  264  of  this  report. 


271 

465  families  where  physical  or  mental  disability  was  the  predominating 
cause  of  dependency. 

The  factor  of  insanity  is  not  unlike  that  of  death  or  that  of  deser- 
tion of  husband  according  as  the  abnormal  mental  condition  is  perman- 
ent or  temporary.  In  fact,  in  practically  every  case  of  the  33  families  re- 
ceiving support  from  charity  because  of  the  insanity  of  the  normal  bread- 
winner, the  husband  and  father  was  confined  in  a  hospital  for  the  insane. 
How  insanity  disintegrates  family  life  and  involves  social  loss  need  not  be 
illustrated  by  concrete  cases. 

In  129  or  27.7  per  cent  of  the  465  families  dependent  because  of 
sickness  or  accident,  the  normal  breadwinner  had  been  completely  or 
partially  unemployed  with  loss  of  wages  or  had  suffered  reduced  economic 
efficiency  and  earning  power  because  of  tuberculosis. 

From  the  standpoint  of  economic  degradation,  the  families  where 
the  main  breadwinner  was  tuberculous  fall  into  two  groups :  36  families 
where  he  was  unable  to  work  at  all  during  the  year,  and  93  families 
where  he  was  able  to  work  from  one  to  fifty-two  weeks  in  the  year.  The 
former  group  is  wholly  dependent  upon  charity  except  where  the  wife 
or  the  older  child  go  to  work  or  where  there  may  be  some  small  source  of 
income.  In  general,  the  economic  degradation  has  here  reached  a  lower 
level  than  where  the  breadwinner  is  still  able  to  continue  work. 

Case  4.  Normal  breadwinner  tuberculous,  fifty-two  weeks  dis- 
abling sickness. — This  Czech  family  of  four  consists  of  father, 
mother,  a  boy  of  nine  years,  and  a  girl  of  four  years.  The  whole 
family  is  affected  with  tuberculosis,  the  father  having  been  in- 
capacitated for  three  years.  Before  his  sickness  he  was  an  assistant 
foreman,  earning  $20  a  week.  The  prior  economic  standing  of  the 
family  is  indicated  by  the  fact  that  the  husband  has  $1,000  policy 
in  Catholic  Foresters;  the  wife,  $600  in  St.  Cecilia.  Their  first 
application  for  charity  was  three  years  ago,  when  the  father  became 
unable  to  work.  They  have  had  no  steady  income  since.  The 
mother  has  worked  "off  and  on"  as  a  saleswoman,  three  days  a  week. 
She  seems  to  be  a  good  worker,  and  has  no  difficulty  in  finding  work, 
when  the  care  of  the  family  allows  her  to  be  away  from  home.  Last 
year  she  earned  something  over  $200.  The  father  is  also  insured 
in  the  Carpenters'  and  Wood-workers'  Union. 

Case  5.  Normal  breadivinner  tuberculous,  less  than  fifty-two 
weeks  disabling  sickness. — Large  German  Polish  family  of  ten  mem- 
bers, father,  mother,  and  eight  children — all  under  ten  years  of  age. 
Father  is  working,  though  in  bad  condition  with  tuberculosis. 
During  the  year  he  earned  around  $1,000.  All  of  the  children  ex- 
cept the  baby  have  tubercular  glands.  The  family  manages  to  get 
something  to  eat,  but  not  the  right  kind  of  food,  and  look  pasty  and 
under-nourished.  They  have  almost  no  clothing,  one  child  having 
nothing  to  wear  but  a  little  suit  of  underclothes.  All  are  bare-foot, 
including  the  mother,  and  all  very  dirty.  The  husband  is  insured 
for  $500  in  St.  Francis'  Society,  the  mother,  in  St.  Mary's  for  the 
same  amount.  The  parents  have  kept  up  industrial  insurance  for 
all  the  children. 


272 

This  case  shows  not  only  that  the  tuberculous  father  is  a  menace  to 
the  health  of  the  little  children  in  the  family,  thus  further  aggravating 
the  sickness  problem  of  the  home,  but  also  that  the  economic  condition 
of  the  family,  already  low,  will  be  very  likely  soon  be  further  depressed 
by  the  physical  inability  of  the  breadwinner  to  continue  at  work. 

Not  unlike  the  difference  between  complete  and  partial  disability 
from  tuberculosis  is  the  economic  degradation  caused  by  "other  chronic 
diseases"  where  the  loss  of  income  because  of  unemployment  from  sick- 
ness is  "fifty-two  weeks,"  or  "less  than  fifty-two  weeks."  The  ailments 
included  under  "chronic  diseases  other  than  tuberculosis"  are  varied; 
heart  trouble,  rheumatism,  cancer,  syphilis,  etc.  The  dependency  of  160 
or  34.4  per  cent  of  the  465  families  studied  was  ascribed  to  chronic  dis- 
eases other  than  tuberculosis.  Forty  of  the  wage-earners  so  disabled 
were  totally  incapacitated  for  fifty-two  weeks. 

Case  6.  Normal  breadwinner,  other  chronic  disabling  sickness 
of  fifty-ttoo  lueeks. — This  Greek  family  has  eight  members  :  husband, 
wife  and  six  children,  the  oldest  a  boy  of  12  years,  the  youngest  a 
baby  of  five  months.  The  father  has  been  unemployed  all  year. 
He  has  done  light  jobs  or  errands  for  the  United  Charities,  and  has 
earned  a  few  cents  or  a  little  food.  At  thirty-six  years  of  age  he  is 
thrown  upon  the  industrial  scrap  pile.  This  man  suffers  from  heart 
lesion  and  rheumatism.  On  account  of  his  heart  the  physician 
states  that  he  will  never  be  able  to  work  hard  or  steadily  again. 
The  mother  is  too  delicate  to  work.  She  has  to  spend  all  her 
time  caring  for  the  children.  It  is  probable  that  the  family  will 
be  charges  on  the  United  Charities  until  the  boys  are  old  enough 
to  work.  It  is  a  fine  family.  They  have  never  taken  out  insurance, 
nor  does  the  husband  belong  to  any  lodge  or  benefit  society. 
One  case  may  suffice  to  illustrate  the  group  of  families  where  chronic 
disease  other  than  tuberculosis  of  the  normal  wage-earner  is  responsible 
for  partial  unemployment  during  the  year. 

Case  7.  Normal  hreadivinner,  other  chronic  disabling  sickness 
less  than  fifty-two  weeks. — The  family  is  composed  of  mother  who 
keeps  house  and  daughter,  Mary,  who  is  over  thirty  years  of  age  and 
is  the  breadwinner  for  the  two.  Mary  was  operated  on  for  car- 
cinoma of  uterus  at  the  Cook  County  Hospital  over  a  year  ago. 
This  operation  has  weakened  her,  and  the  doctor  says  she  must  be 
very  careful — cannot  do  any  kind  of  hard  work.  Mary  cannot 
secure  a  better  position  because  the  physical  examinations  the  vari- 
ous firms  make  every  employee  go  through  are  too  rigid.  She  fails 
every  time  to  pass  such  examinations.  Only  in  factories  where 
physical  examinations  are  not  required  does  she  secure  work.  Mary 
would  like  to  secure  some  additional  work  to  do  at  home  in  the 
evening,  such  as  addressing  envelopes. 

The  effect  of  physical  defects  is  not  unlike  that  of  chronic  disease 
in  the  process  of  economic  degradation.  Included  under  this  term  are 
not  only  blindness,  deaf  mutism,  crippled  limbs,  but  also  severe  hernias. 
In  18  or  3.9  per  cent  of  the  465  families  the  dependency  of  the  family 
was  ascribed  to  physical  defect  of  the  chief  breadwinner.  The  following 
is  a  cause  of  partial  unemployment  in  the  year  due  to  hernia. 


273 

Case  8.  Normal  breadwinner,  physical  defect. — This  family 
of  father,  mother,  and  five  children  under  15  years  of  age,  came  to 
the  attention  of  the  charities  in  November,  1917,  because  of  distress 
due  to  illness  of  breadwinner.  Man  was  referred  to  a  dispensary. 
The  case  was  diagnosed  as  hernia.  He  was  operated  on  in  Feb- 
ruary, 1918.  Since  then  he  was  unable  to  work  as  plasterer  and  was 
given  several  positions.  He  worked  four  weeks  for  the  railroad  com- 
pany and  lost  his  job  because  of  an  industrial  accident.  He  re- 
ceived $100,  compensation.  This  money  the  family  spent  for  furni- 
ture to  replace  what  was  taken  away  by  the  furniture  store  when 
they  failed  to  meet  their  contract  and  pay  the  installments  on  it. 
-  After  the  man  recovered  from  his  accident  he  was  "placed"  in  a 
biscuit  factory,  but  was  obliged  to  leave  at  the  end  of  two  weeks  as 
work  was  too  hard ;  he  was  later  found  a  position  in  a  downtown  de- 
partment store,  w^here  he  worked  one  week  and  was  discharged  he- 
cause  of  illness.  The  family  has  lived  upon  the  partial  support  of 
the  charities  and  the  man^s  occasional  earnings  which  amount  to 
little  over  $100  for  the  entire  year. 

Accidents,  non-industrial  or  industrial,  sustained  by  the  normal 
breadwinner  were  assigned  as  chief  cause  of  dependency  in  49  or  10.5 
per  cent  of  the  465  families.  Twenty-three  of  these  cases  were  designated 
as  industrial  accident,  fifteen  as  non-industrial,  and  in  eleven  cases  the 
information  did  not  disclose  the  circumstances  of  injury  from  accident. 
Accidents,  involving  disability,  lead  either  to  an  acute  but  tem- 
porary economic  depression  or  to  a  long  time  economic  degradation. 
The  following  illustration  of  non-industrial  accident  shows  how  dis- 
ability from  injury  constitutes  a  crisis  which  may  temporarily  or  perm- 
anently lower  the  economic  and  social  standing  of  the  family. 

Case  9.  Normal  breadwinner.  Disabling  injury  by  non- 
industrial  accident. — Mr.  F.  is  a  laborer  in  the  steel  mills  earning 
$26.60  a  week.  He  was  able  to  meet  the  ordinary  requirements  of 
home  economy  for  wife  and  three  little  children  6,  4,  and  3  years 
old  until  he  was  taken  to  a  hospital  on  account  of  injury.  This 
occurred  the  night  the  youngest  child  was  born.  He  was  way-laid 
by  two  men  and  so  injured  that  an  operation  was  necessary.  It 
was  five  months  before  he  was  able  to  resume  his  work.  This 
accounts  for  the  aid  given  by  the  Charity  Association,  and  the 
company  and  the  help  otherwise  given.  Moreover,  it  accounts,  for 
the  borrowed  money  and  the  doctor^«^  bill  of  $125.  Had  there  been 
adequate  health  or  accident  insurance  there  would  not  have  been 
the  need  for  charity  nor  for  borrowing  money  ($75  to  pay  the 
hospital  bill),  nor  the  large  doctor^s  bill,  $125  still  due.  All  these 
things  are  a  handicap  to  the  family  now.  Fortunately  the  father 
has  recently  received  an  increase  in  wages  which  will  probably  make 
it  possible  for  the  family  to  regain  its  normal  economic  independ- 
ence. At  the  time  of  the  visit  of  the  investigator  the  front  room 
had  nice  clean  curtains  at  all  the  windows,  and  the  rug  and  floor 
were  quite  clean. 

—18  H  1 


274 

Although  Illinois  has  made  provision  for  compensation  for  in- 
dustrial accident,  the  menace  of  economic  loss  is  not  wholly  removed 
for  while  the  law  is  compulsory  in  "extra  hazardous  employments/'  it 
is  elective  in  other  employments  and  a  considerable  number  of  firms 
do  not  come  under  it.  Moreover,  there  are  occasional  instances  in  which 
there  are  delays  in  making  settlements  under  the  law.  Among  the 
cases  included  in  the  investigation  were  23  growing  out  of  industrial 
accidents. 

Acute  illness  of  chief  wage-earner  was  assigned  as  the  predomina- 
ting cause  of  dependency  in  60  or  13.0  per  cent  of  the  465  families. 
Acute  illness  differs  from  chronic  sickness  in  that  the  economic  losses, 
though  often  large,  are  temporary.  A  series  of  acute  illnesses  of  mem- 
bers of  the  family  may  involve  serious  cost.  "x\in't  been  a  week  there 
ain't  been  a  sickness  in  this  house,"  was  the  statement  of  an  old  colored 
woman.  Where  thousands  of  wage-earning  families  live  on  the  seven- 
day  budget  allowed  by  the  weekly  pay  envelope,  disabling  sickness  of 
the  normal  breadwinner,  if  only  for  a  week,  certainly  where  it  is  for 
several  weeks,  brings  pecuniary  stress  and  strain  which  may  result  in 
economic  depression  into  dependency.  The  following  case  is  not  un- 
typical of  this  sickness  group. 

Case  10.  Normal  hreadivmner,  acute  illness. — Mr.  B  and  Mrs. 
B.  were  born  in  Hungary.  Of  five  children  the  oldest  is  twelve. 
The  family  lives  in  a  frame  cottage  badly  in  need  of  repair.  The 
home  is  poorly  furnished,  the  floors  are  bare,  the  windows  cur- 
tainless,  but  everything  is  clean.  The  children  and  their  mother 
are  well  and  neatly  dressed.  The  father,  a  worker  in  the  railroad 
car  shops  for  over  four  years,  earns  from  $25  to  $30  a  week,  but 
much  of  the  money  went  for  coal  last  year,  Mrs.  B.  says,  and  each 
week  the  grocery  bill  is  high.  In  April  Mr.  B.  caught  a  severe 
cold  and  was  ill  in  bed  for  three  weeks,  during  which  time  he 
received  no  salary,  and,  as  they  live  up  to  every  penny,  the  family 
had  no  money  during  his  illness,  so  they  appealed  to  the  charities. 
During  the  man's  illness  the  wife  received  credit  at  the  grocery 
store,  and  since  his  return  to  work,  she  has  paid  off  the  grocery  bill, 
and  also  the  doctor's  bill. 

In  only  16  or  3.4  per  cent  of  the  465  families  was  the  illness  of 
some  member  of  the  family  rather  than  disabling  sickness  of  the  normal 
breadwinner  the  major  cause  of  dependency.  The  small  number  of 
families  in  this  group  indicates  that  the  loss  of  wages  of  the  normal 
breadwinner  is  in  general  more  important  as  a  cause  of  dependency  than 
disabilities  of  other  members  of  the  family,  even  where  the  expenditure 
for  medical  care  runs  high.  Economic  stress  and  strain,  severe  retrench- 
ment, lowered  standards  of  living,  are  involved,  but  seldom,  as  in  the 
following  case,  actual  dependency. 

Case  11.  Sickness  of  other  memher  of  family. — Mr.  and  Mrs. 
M.  each  came  to  America  alone  about  five  years  ago.  They  have 
but  few  relatives  in  Poland  and  only  a  cousin  of  Mrs.  M.'s  in 
Chicago.  They  got  along  very  well  after  they  were  married,  and 
lived  in  a  nice  flat  until  Mrs.  M.  became  ill  before  her  first  con- 
finement last   September.     Mr.   M.  had  to  give  up  his  work  as 


275 

chauffeur  and  his  wages  of  $20  a  week  to  care  for  her.  She  later 
went  to  a  private  hospital  where  the  expense  was  $4  per  day.  This 
took  all  of  Mr.  M.'s  earnings  and  involved  him  in  a  debt  of  over 
$300.  The  baby  was  born  at  the  hospital  and  was  sick  afterwards 
for  a  long  time.  Finally  it  was  taken  to  the  Cook  County  Hospital. 
The  family  did  not  ask  aid  of  the  United  Charities  or  any  one, 
but  were  heard  of  and  helped.  Mrs.  M.  had  $500  when  she  married. 
Mr.  and  Mrs.  M.  bought  a  lot  upon  which  they  still  owe  $130.  The. 
baby  is  well  now.  Mrs.  M.  does  janitor  work  in  return  for  rent. 
The  actual  family  income  for  the  5^ear  was  $636  instead  of  $1,000 
as  would  normally  have  been  expected.  Mr.  M.  is  saving  his  salary 
to  pay  debts.  They  are  very  anxious  to  move  •  to  a  better  flat. 
They  belong  to  a  Polish  church  on  the  west  side  of  the  city,  but 
do  not  have  clothing  now  to  go  anywhere.  They  are  ambitious  and 
hopeful. 
In  summing  up  the  role  of  disabling  sickness  by  types  of  disability 

in  the  process  of  economic  degradation  the  outstanding  conclusions  may 

be  restated: 

(1)  In  disrupted  families  where  the  normal  breadwinner  is  dead 
or  has  deserted,  disabling  illness  ought  not  to  be  considered  as  a  cause, 
but  rather  as  a  condition  of  dependency.  Indeed,  investigation  indi- 
cates that  in  these  families  sickness  was  often  a  result  of  an  already 
degraded  economic  condition. 

(2)  In  families  not  disrupted  disabling  illness  (of  whatever  type) 
of  the  breadwinner  is  preponderantly  the  cause  of  dependency.  In  only 
16  cases  out  of  465,  or  3.4  per  cent,  was  sickness  of  a  member  of  the 
family  other  than  the  normal  breadwinner  found  to  be  the  predomi- 
nating cause  of  dependency.  In  a  larger  proportion  of  families,  sick- 
ness of  a  member  other  than  the  normal  breadwinner  is,  of  course,  a 
contributing  cause,  and  in  nearly  all  families  a  condition,  if  not  a 
result,  of  dependency. 

(3)  Chronic  sickness,  including  tuberculosis  of  the  normal  bread- 
winner, is  clearly  the  type  of  disability  resulting  in  the  most  complete 
and  permanent  economic  and  social  degradation  not  only  because  of  the 
size  of  the  group  affected  (40  to  50  per  cent  of  all  physical  disability 
aside  from  accident)  but  also  because  of  the  long-time  nature  of  the 
consequent  economic  incapacity. 

(4)  The  vicious  circle  of  sickness  and  poverty  is  fully  exemplified 
by  the  circular  interaction  of  tuberculosis  and  economic  degradation. 
Lowered  economic  status,  with  reduced  standards  of  diet,  predisposes  to 
tuberculosis;  tuberculosis  of  the  chief  wage-earner  in  turn  involves 
diminished  earning  capacity  and  loss  of  time  and  wages.  This  degraded 
economic  status  makes  impossible  the  standards  of  housing,  clothing 
and  food  necessary  for  improvement  and  recovery  of  health.  Although 
medical  treatment  is  now  free  (at  the  Municipal  Tuberculosis  Sani- 
tarium), the  infection  of  the  wife  and  children  ("all  except  the  babV') 
requires  the  special  tuberculosis  diet  which  augments  the  rapidly  grow- 
ing disparity  between  his  earnings  and  the  income  required  to  provide 
for  the  health  needs  of  the  family  group. 


276 

(b)   Relation  of  Dependency  Caused  by  Sickness  to  Normal  Economic 
Condition  of  Family. 

The  Commission  was  interested  in  discovering  not  only  the  types 
of  disabilities  making  for  destitution,  but  also  more  especially  the 
nature  of  the  economic  changes  resulting  both  from  sickness  as  a  whole 
and  from  the  various  forms  of  disabilities.  The  effect  upon  standards 
of  family  life  from  a  chronic  illness  such  as  heart  disease,  will  be,  in 
general,  quite  different  from  that  resulting  from  a  temporary  acute  ill- 
ness such  as  bronchitis.  At  the  same  time,  families  of  different  economic 
levels  will  be  variously  affected  by  the  same  type  of  illness.  A  loss  of  a 
week^s  work  may  be  only  a  temporary  inconvenience  to  one  family,  but 
a  long  time  economic  degradation  to  another. 

Normal  economic  status  of  the  family  was  based  upon  the  actual 
family  income  augmented  by  wages  lost  by  the  sickness  of  wage-earner 
during  the  year.  It  should  be  distinguished  from  actual  economic 
status — which  is  determined  by  the  actual  family  income  diminished  by 
direct  outlays  on  account  of  sickness.  For  finding  out  the  relation  of 
economic  condition  to  sickness,  the  normal  in  preference  to  the  actual 
economic  status  was  selected  since  it  was  the  usual  income  level  as 
related  to  family  needs  and  habits  of  life  before  the  incidence  of  sickness. 

In  order  to  grade  differences  in  the  normal  economic  status  of  the 
family  with  rough  precision,  the  families  were  grouped  into  the  following 
four  classes  :*^ 

Class  A.  Families  with  "higher  income"  sufficient  to  provide  for  the 
necessities  and  certain  of  the  decencies  of  life. 

Class  B.  Families  with  "meagre  income"  sufficient  to  provide  at 
least  for  the  bare  necessities  of  life. 

Class  C.  Families  with  "low  income"  insufficient  to  provide  for  the 
bare  necessities  of  life. 

•    Class  D.  Families  not  assigned  to  the  above  classes  because  of  in- 
complete reports  of  annual  income. 

The  normal  economic  status  as  determined  in  this  way  for  the  628 
charity  families  was  as  follows:  Class  A,  68;  Class  B,  139;  Class  C, 
401;  Class  D,  20.  That  nearly  two-thirds  (63.9  per  cent)  of  the  fami- 
lies were  in  Class  C  is  due  to  the  fact  that  "normal"  economic  status 
refers  only  to  the  year  under  study.  No  adequate  data  were  available 
for  ascertaining  earlier  family  income  completely.  In  cases  of  the  death 
of  the  wage-earner  before  the  present  year,  or  in  cases  of  one  or  more 
years  of  partial  or  complete  disability  from  tuberculosis,  the  use  of  the 
present  year  for  deciding  economic  status  is  open  to  criticism.  If  the 
income  history  of  the  family  for  a  period  of  the  last  five  years  had  been 
accessible  as  the  basis  for  determining  the  normal  economic  status,  the 
number  of  families  in  Classes  A  and  B  would  have  been  increased,  and 
the  number  in  Class  C  correspondingly  diminished.  In  the  absence  of 
data  for  a  period  of  years,  it  was  necessary  to  use  the  only  available 
basis,  that  of  the  year  of  the  study. 

*^  See  the  Introduction  of  this  report  for  a  detailed  explanation  of  the  exact 
method  of  arriving  at  the  dividing  lines  between  these  four  classes  by  economic 
status,  pp.  185-90. 


277 


The  distribution  into  classes  by  economic  status  of  2,708  wage- 
earning  families  in  the  blocks  studied  makes  possible  the  following  com- 
parison with  the  economic  status  of  the  628  charity  families.' 


Normal  economic  status. 


Number  of  families  in 


Block 
study. 


Charity 
study. 


Per  cent  families  in 


Block 
study. 


Charity 
study. 


Class  A  with  higher  income 

Class  B  with  meager  income 

Class  C  with  deficient  income 

Class  D  with  income  not  reported 

Total 


1,687 
631 
280 
110 


68 
139 
401 

20 


2,708 


628 


62.3 

23.3 

10.3 

4.1 


100.0 


10.8 

22.1 

63.9 

3.2 


100.0 


A  superficial  examination  of  this  table  indicates  for  block  and 
charity  families  almost  an  exact  reversal  of  the  proportions  in  groups 
A  and  C  with  practically  no  change  in  the  percentage  in  group  B. 
Taking  the  proportions  at  their  face  value  it  would  appear  that  families 
in  Class  C  (with  deficient  incomes)  were  6.5  times  as  likely  as  families 
in  Class  B  (with  meager  incomes)  and  35.9  times  as  likely  as  families 
in  Class  A  (with  higher  incomes)  to  be  depressed  through  sickness  into 
dependency.  These  figures,  however,  exaggerate  the  relative  pressure 
of  sickness  upon  the  poor  (Class  C).  Class  C  in  the  charity  group  (in 
contrast  to  the  block  group)  contains  a  large  but  indeterminate  pro- 
portion of  families  where  chronic  diseases  and  other  long-time  disabili- 
ties had  reduced  the  family  from  its  normal  economic  level  before  the 
year  of  the  study.  It  is,  therefore,  manifestly  beside  the  point  to  make 
a  straight  comparison  between  the  normal  economic  status  of  Class  C 
families  in  the  block  and  in  the  charity  studies.  The  figures  of  the 
tables  may  be  taken  only  as  confirming  the  common  sense  observation 
(which  is  so  obvious,  perhaps,  as  to  need  no  statistical  demonstration) 
that  families  in  poverty,  close  to  the  margin  of  destitution,  are  more 
easily  pushed  into  dependency  by  sickness  or  other  misfortune. 

The  following  table  is  significant  as  indicating  the  normal  economic 
status  (for  the  year  of  the  study)  of  the  charity  families  classified  by 
the  kind  of  distress  assigned  as  the  cause  of  dependency: 


278 


Cause  of  distress. 


Num- 
ber of 
fam- 
ilies. 


Normal  economic  status. 


Cla;ss  A 
(higher 

in- 
comes). 


Class  B 
(meager 

in- 
comes). 


Class  C 

(defi- 
cient in- 
comes). 


Class  D 

(not 
reporting 

as  to 
income). 


Families  disrupted — 
^  By  death  of  adult  male  breadwinner  (before  year). . 
H  By  death  of  adult  male  breadwinner  (during  year). . 

By  desertion 

Families  not  disrupted — 

Disabihty  of  normal  breadwinner  cause  of  dependency— 

By  old  age 

By  insanity 

By  tuberculosis  (not  working  in  year) 

By  tuberculosis  (working  in  year) 

By  chronic  other  than  tuberculosis  (not  working  in 

year)  

By  chronic  other  than  tuberculosis  (working  in  year) 

By  physical  defect , 

By  injury  through  accident ^ , 

By  acute  illness 

Disabihty  of  normal  breadwinner  not  cause  of  depend 
ency — 

Sickness  in  family  the  cause 

Sickness  not  the  cp,use 

All  families 


55 

2 

10 

43 

25 

4 

3 

13 

37 

2 

34 

8 

1 

1 

6 

33 

1 

6 

25 

36 

1 

32 

93 

9 

24 

58 

40 

1 

5 

31 

120 

21 

34 

65 

18 

1 

2 

14 

49 

8 

23 

17 

60 

10 

17 

30 

16 

38 

4 
5 

5 

7 

7 
26 

628 

■  68 

139 

401 

5 
1 


1 
3 
2 


1 
1 
3 


20 


Note-worthy  differences  by  causes  of  distress  appear  upon  a  study 
of  this  table. 

1.  In  cases  of  disability  for  a  period  exceeding  twelve  months  (i.  e. 
tuberculosis  and  other  chronic  diseases  and  physical  defects)  the  normal 
economic  status  for  the  year  of  the  study  is  predominantly  in  Class 
C  ("A''  cases  3.2  per  cent,  "B''  cases  7.4  per  cent,  "C"  cases  81.9 
per  cent,  "D"  cases  7.4  per  cent). 

2.  In  cases  of  disability  for  a  period,  presumably  of  less  than 
twelve  months  (i.  e.  injury  through  accidents,  acute  illness)  the  pro- 
portion in  Class  C  is  less  than  half  ("A^^  cases  16.5  per  cent,  "B"  cases 
36.7  per  cent,  "C"  cases  43.1  per  cent  and  "D"  cases  3.7  per  cent.)  The 
only  conclusion  to  be  drawn  from  this  comparison  is  that  the  normal 
economic  status  for  the  year  of  the  study  does  not  denote  the  original 
normal  economic  status  of  the  chronic  cases  where  the  disability  begins 
before  the  twelve  months  covered  by  the  study  and  that  the  normal 
economic  status  of  families  with  temporary  disability  more  adequately 
represents  the  economic  level  of  families  in  the  charity  study  before  the 
appearance  of  the  disability  responsible  for  the  present  distress. 

The  assumption  that  at  least  half  of  the  families  were  in  Classes 
A  and  B,  above  the  subsistence  level  and  successfully  meeting  all  risks 
of  life  except  sickness,  finds  corroboration  in  certain  other  facts.  De- 
spite the  families  forced  to  give  up  policies  because  of  need,  70.7  per 
cent  had  one  or  more  members  with  life  insurance.  Of  the  husbands 
of  wage-earning  families,  56.9  per  cent  had  life  insurance.  The  per 
cent  (20.0)  of  the  wage-earning  husbands  of  charity  families  with  dis- 
ability policies  (or  membership  rights)  indicates  their  attempt  to  pro- 
vide against  sickness"  hazards  within  the  present  organization  of  health 
insurance.  Many  wage-earners  in  charity  families  were,  or  prior  to 
sickness,  had  been  members  of  trade  unions.     On  the  whole,  the  group 


279 

of  628-  wage-earning  families  before  the  occasion  of  disabling  illness 
seems  not  to  have  differed  from  the  independent  families  in  the  block 
study  except  in  the  undoubtedly  smaller  proportion  in  Classes  A  and  B 
and  the  larger  relative  number  in  Class  C. 

In  order  to  prove  or  disprove  this  tentative  conclusion,  additional 
data  in  regard  to  the  economic  standing  of  the  charity  families  before 
the  year  of  the  study  were  secured.  The  story  of  the  family,  as  en- 
tered on  the  schedule  used  in  the  study  and  compiled  from  the  charity 
records  and  from  visits  to  the  homes,  provided  evidence  of  the  economic 
standing  of  291  (out  of  G28)  families  before  the  time  when  the  last 
(in  many  cases  the  first)  appeal  was  made  for  relief.  On  the  basis  of 
this  information  families  were  divided  into  the  following  groups  by 
economic  standing  prior  to  present  dependency. 

(1)  Families  normally  indevendent. — Families  known  not  to  have 
been  in  serious  economic  distress  or  to  have  been  dependent  before  the 
present  condition  of  distress  were  classified  as  "families  normally  in- 
dependent." 

(2)  Dependent  families. — Families  known  to  have  been  dependent 
or  in  economic  distress  before  the  present  occasion  for  appeal  for 
relief  were  classified  as  "dependent  families."  These  dependent  families 
were  further  divided  into  (1)  families  previously  dependent  because  of 
illness,  (2)  families  previously  dependent  without  illness,  and  (3) 
families  previously  dependent  with  no  report  in  regard  to  illness.  Of 
the  291  families  where  information  on  this  point  was  available,  149 
were  assigned  to  the  group  of  normally  independent,  and  142  were 
entered  as  dependent  prior  to  the  last  occasion  of  distress.  The  reasons 
for  the  dependency  of  28  of  these  142  were  not  ascertained.  Of  the 
remaining  114,  40  had  been  dependent  because  of  sickness,  74  for  other 
reasons.  It  seemed  desirable,  therefore,  to  combine  the  families  nor- 
mally independent  with  the  families  dependent  previously  because  of 
sickness  and  to  present  the  data  by  detailed  causes  of  dependency  as 
indicated  in  Table  29. 

The  following  conclusions  may  be  drawn  from  an  examination  of 
this  table: 

(a)  Of  291  families  reporting  earlier  economic  standing,  189  or 
64.9  per  cent  had  been  able  to  maintain  against  all  the  risks  of  life 
except  sickness  an  independent  economic  existence  prior  to  the  present 
occasion  of  distress;  74  families,  or  25.4  per  cent,  were  previously  de- 
pendent without  disabling  sickness;  for  28  families,  or'  9.6  per  cent, 
the  cause  of  previous  dependency  was  not  recorded. 

(b)  Of  195  families  where  physical  disability  (excluding  old  age) 
was  the  occasion  of  present  distress,  135,  or  69.2  per  cent,  were  assigned 
as  previously  aside  from  sickness  economically  independent;  42  families, 
or  21.5  per  cent,  were  previously  dependent  without  disabling  sickness; 
for  18  families,  or  9.2  per  cent,  the  cause  of  earlier  dependency  was 
not  reported. 

(c)  Although  the  numbers  are  small,  it  is  quite  significant  that 
the  proportion  of  families  with  prior  dependency  without  sickness  is 
highest  where  the  present  occasion  of  distress  is  "desertion'^  or  ''sick- 
ness not  the  cause." 


280 

The  three  chief  points  brought  out  in  the  analysis  of  the  relation 
of  dependency  caused  by  sickness  to  the  normal  economic  condition  of 

the  family  are  as  follows: 

(1)  The  poverty  group  (Class  C),  as  expected,  contributed  to 
the  condition  of  dependency  a  much  larger  relative  number  of  its  fami- 
lies than  did  the  groups  above  the  subsistence  level  (Classes  A  and  B). 

(2)  Yet,  as  indicated  by  families  dependent  because  of  temporary 
sickness,  the  original  normal  economic  status  of  one-half  or  more  of 
dependent  families  was  undoubtedly  in  Classes  A^and  B. 

(3)  Furthermore,  a  special  study  of  291  of  the  628  families  showed 
that  at  least  189  (64.9  per  cent)  before  the  present  appeal  for  relief 
had  been  (except  for  sickness)  economically  independent. 

(c)  Large  Size  of  Family  as  a  Factor  Interrelated  With  Sickness  in 
Causing  Dependency. 

Sickness,  even  where  a  major  cause  of  dependency  may  of  course 
be  only  one  factor  in  a  combination  of  factors.  Some  other  factor, 
such  as  large  size  of  family,  often  raises  the  inquiry,  is  not  this  condi- 
tion in  itself,  without  the  complication  of  disease  sufficient  to  account 
for  the  status  of  dependency?  Or  the  question  may  be  raised,  shall 
we  be  satisfied  with  the  statement  of  disabling  sickness  as  a  factor? 
Should  we  not  look  into  its  causal  antecedents,  into  malnutrition,  into 
housing,  into  conditions  of  work  and  into  climate  as  underlying  and 
permanent  causes?  The  Commission  realized  that  it  had  neither  the 
time,  funds,  money  nor  staff  to  undertake  an  exhaustive  investigation 
into  these  and  other  conditions  as  causes  of  poverty.  However,  it  is 
possible  to  present  here  data  upon  the  size  of  the  family  as  related  to 
sickness  and  to  dependency. 

Largeness  of  family  as  a  cause  of  dependency  has  never  been  satis- 
factorily treated  by  the  students  of  the  problem  of  poverty. 

Warner*^  concludes  that  "large  families  are  a  relatively  unim- 
portant cause  of  destitution.^^  This  generalization  is  on  the  basis  of  a 
classification  of  more  than  four  thousand  charity  cases  in  Boston  and 
New  York  "52  per  cent  had  one  to  three  children  and  only  18  per  cent 
had  more  than  five  children.^^  No  statement  is  given  of  the  relative 
number  of  families  without  children,  nor  the  age  of  the  children;  all 
crucial  points  in  determining  the  relation  of  the  size  of  the  family  to 
poverty  and  dependency. 

The  Immigration  Commission  does  not  list  large  families  as  an 
apparent  reason  why  any  of  the  31,374  families  studied  appealed  for 
relief,  19.9  per  cent  of  these  families  are  reported*^  as  with  "insuffi- 
cient earnings"  which  may  have  included  "large  size  of  family"  as  well 
as  many  other  conditions. 

Devine  in  his  studies  in  New  York  introduces  as  a  definition  of 
large  size  of  family  "families  with  more  than  three  children  under 
fourteen."  He  found  that  18.9  per  cent  of  one  group  of  5,000  depend- 
ent families*^  and  that  16.9  of  another  group  of  1,000  dependent 
families*^  had  more  than  three  children  under  fourteen.    In  appraising 

«Op.  cit.  p.   59. 
«Op.   cit.   p.   120-1. 
"Op.   cit.   p.    204. 
"Op.  cit.  p.   228. 


281 


TABLE    29- 


-PRIOR   ECONOMIC    STANDING    OF    291    FAMILIES,    CLASSIFIED 
BY  CAUSE  OF  DISTRESS. 


Cause  of  distress. 


Families 

with  report 

of  prior 

economic 

standing. 


Families 
normally 

inde- 
pendent or 
dependent 

sickness. 


Families 

dependent 

without 

sickness. 


Families 
dependent 
no  report 

as  to 
sickness. 


Families  disrupted — 

By  death  of  adult  male  wage  earner  (80) 

By  desertion  (37) 

Families  not  disrupted — 

Disability  of  normal  bread  winner  cause  of  depen- 
dency— 

By  old  age  (8) 

By  insanity  (33) 

By  tuberculosis  (129) 

By  chronic  disease  other  than  tuberculosis 

(160). 

By  physical  defect  (18) 

By  mjury  from  accident  (49) 

By  acute  illness  (60) 

Disability  of  normal  bread  winner  not  cause  of 
dependency — 

Sickness  in  family  cause  (16) 

Sickness  not  the  cause  (38) 

All  families  (628) 


33 
13 


1 

15 
60 

79 

7 

37 

22 


11 

23 

291 


27 
5 


1 
9 

38 

59 

4 

21 

13 


4 

8 

189 


5 
9 

12 

2 

12 

7 


3 

14 

74 


3 
1 


1 
3 

8 
1 
4 
2 


4 
1 

28 


282 


this  finding  by  Devine,  it  is  necessary  to  give  due  weight  to  the  fact 
of  the  unusually  high  rate  of  unemployment  in  the  year  covered  in  his 
investigation  which  consequently  lowered  the  normal  proportion  of  all 
the  more  constant  causes  of  dependency. 

The  charitable  agencies  of  Chicago,  while  they  may  report  separ- 
ately the  size  of  the  family,  do  not  list  it  among  causes  of  dependency. 
The  large  family  as  a  cause  of  dependency  may  of  course  be  included 
under  the  term  "insufficient  earnings.^^  The  ambiguity  of  this  omnibus 
well-meaning  but  unmeaning  phrase  should  long  ago  have  led  to  its 
disuse  by  relief  agencies.  It  is  undeniably  desirable  to  know  whether 
"insufficient  earnings"  denotes  "insufficient  earnings  because  the  wage- 
rate  of  employer  is  below  the  normal  industrial  rate,"  or  "insufficient 
earnings  because  of  the  reduced  earning  capacity  of  wage-earner  from 
specified  causes,"  or  "insufficient  earnings  because  the  normal  rate  of 
wages  is  inadequate  to  meet  the  needs  of  subsistence  of  a  family  of 
large  size." 

For  these  reasons  we  have  determined  upon  a  definition  of  large 
size  of  familv  from  the  standpoint  of  the  relation  between  income  from 
wages  and  requirements  of  a  standard  of  living  providing  at  least  for 
the  bare  necessities  of  life,  and  in  addition,  if  possible,  for  its  decencies, 
and,  to  a  limited  extent,  for  its  comforts.  A  large  family  was,  there- 
fore, defined  as  one  with  more  than  three  children  not  over  fourteen 
years  of  age  and  in  which  there  was  only  one  wage-earner.  The  prin- 
ciple underlying  the  selection,  by  all  students  of  standards  of  living, 
of  three  children  under  fourteen  as  the  basis  of  the  determination  of  the 
adequacy  of  wages  was  accepted  and  applied  here.  The  presence  of 
only  one  actual  or  potential  wage-earner  in  the  family  is,  however,  an 
added  limitation.  Children  fifteen  years  of  age  or  over,  even  if  not 
actually  earning  wages  during  the  year,  were  considered  as  additional 
wage-earners. 

The  following  table  indicates  quite  clearly  the  correlation  between 
the  size  of  the  family  and  the  actual  economic  status  in  our  block  and 
charity  studies: 


Actual  economic  status  or  condition  of  dependency. 


Number  of 

wage 

earning 

families. 


Large  families;  four  or  more 
children  not  over  14  years 
and  only  one  wage  earner. 


Number. 


Per  cent. 


Block  families 

Class  W  with  highest  incomes. 
Class  A  with  higher  incomes . . 
Class  B  with  meager  incomes . 
Class  C  with  deficient  incomes 
Charity  families 


2,598 
893 
644 
686 
375 
628 


252 
9 
22 
101 
120 
229 


9.7 
1.0 
3.4 

14.7 
32.0 
36.5 


This  table  provides  data  for  the  conclusion  that  the  economic  status 
of  the  family  varies  inversely  with  its  size.  At  the  same  time  the 
slightly  higher  proportion  of  large  families  in  the  charity  as  compared 
with  the  poverty  (Class  C)  group  apparently  indicates  that  largeness 
of  family  is  seldom  an  immediate  cause  of  dependency.  The  relatively 
high  proportion  of  large  families  in  the  poverty  and  dependency  groups 


283 


calls  seriously  into  question  Warner's  statement  that  "large  families 
are  a  relatively  unimportant  cause  of  destitution."  Or  can  a  percentage 
for  large  size  of  families  twice  as  high  as  that  found  by  Devine  be 
explained  sufficiently  by  differences  between  New  York  and  Chicago 
and  by  the  unusual  unemployment  of  a  decade  ago  ? 

Our  study  of  291  charity  families  who  furnished  data  in  regard  to 
economic  standing  prior  to  the  present  occasion  of  distress  made  possible 
an  indirect  study  of  the  relation  of  large  families  to  chronic  dependency. 
Of  the  291  charity  families,  99  or  34.0  per  cent  had  four  or  more  chil- 
dren not  over  fourteen  years  of  age.  Of  the  189  families  who  were 
previously  independent,  or  dependent  only  because  of  sickness,  55,  or 
29.1  per  cent  were  of  large  size.  Of  the  102  families  either  dependent 
without  sickness  or  not  reporting  as  to  sickness,  44  or  43.1  per  cent 
were  of  large  size.  The  fact  that  the  proportion  of  families  of  large 
size  was  48.1  per  cent  higher  where  families  had  been  dependent  with- 
out sickness,  including  those  where  status  as  related  to  sickness  is  not 
known,  than  where  families  had  been  previously  independent  or  depend- 
ent with  sickness  indicates  a  fundamental  if  not  a  direct  relation  between 
size  of  family  and  dependency. 

In  an  attempt  to  exhibit  a  certain  definite  interrelation  between 
size  of  family  and  cause  of  dependency  by  type  of  distress,  the  following 
table  has  been  prepared : 


• 

All 

families 
studied. 

Large 
families  i.  e. 

with  one 

wage  earner 

but  four  or 

more 

children 

not  over 

14  years. 

Large 

families 

per  cent  of 

total 

families. 

Families  disrupted— 

By  death  of  adult  male  wage  earner 

B  V  desertion  of  adult  male  wage  earner 

80 
37 

8 
33 
129 
160 
18 
49 
60 

16 
38 

628 

16 
6 

0 
14 
57 
67 

4 
17 
27 

5 

16 

229 

20.0 
16.2 

Famifies  not  disrupted — 

Disability  of  normal  bread  winner  cause  of  dependency— 
B V  old  age 

00.0 

Bv  insanity 

42.4 

Bv  tuberculosis  ...                                 

44.2 

Bv  chronic  disease  other  than  tuberculosis   .... 

41.9 

Bv  physical  defect 

22.2 

By  miury  from  accident 

34.7 

By  acute  illness 

45.0 

Disability  of  normal  bread  winner  not  cause  of  depen- 
dency- 
Sickness  in  family  the  cause 

31.2 

Sickness  not  a  cause    

42.1 

All  families            . .                  

36.5 

Although  the  number  of  cases  is  small  for  certain  types  of  distress, 
larger  numbers  would  in  all  probability  validate  the  following  con- 
clusions : 

(a)  The  proportion  of  large  families  where  the  cause  of  distress 
is  insanity,  tuberculosis,  other  chronic  disease,  acute  illness  and  where 
sickness  is  not  a  cause,  it  uniformly  high — over  40  per  cent. 

(b)  In  disrupted  families  and  in  cases  of  physical  defect  the  per- 
centage of  large  families  is  relatively  low,  that  is,  under  twenty-five  per 


284 

cent.  The  small  proportion  of  dependent  disrupted  families  with  more 
than  three  children  is  perhaps  to  be  ascribed,  in  part,  to  the  extent  that 
widows  and  deserted  wives  with  children  are  provided  for  by  allow- 
ances under  the  Funds  to  Parents  Law.  The  small  proportion  of  large 
families  where  the  breadwinner  is  disabled  by  physical  defect  is,  in  great 
measure,  to  be  attributed  to  the  large  number  of  cases  in  which  the  early 
appearance  of  the  defect  delays  marriage,  or  its  late  origin  occurs  after 
one  or  more  children  are  past  fifteen  years  of  age. 

(c)  The  moderate  percentage  of  large  families  where  the  cause  of 
dependency  is  assigned  to  injury  from  accident  provides  a  lead  for  de- 
termining the  interrelation  of  disabling  sickness  and  the  large  size 
of  the  family.  The  proportion  of  large  families  where  the  cause  for  de- 
pendency is  assigned  to  injury  from  accident  is  34.7  per  cent;  to  chronic 
diseases  including  tuberculosis,  42.9  per  cent;  and  to  acute  illness,  45.0 
per  cent.  In  injury  from  accident,  as  well  as  in  disabling  sickness^  a 
large  family  will  predispose  to  an  acceleration  of  the  process  of  economic 
degradation  ending  in  dependency;  but  it  is  difficult  to  understand  how 
a  large  family  would  predispose  to  accident.  The  fact,  then,  that  the 
proportion  of  large  families  is  from  one-fourth  to  one-third  greater  in 
dependent  families  where  the  cause  of  distress  is  attributed  to  acute  and 
chronic  illnesses  than  where  it  is  assigned  to  injury  by  accident  suggests 
that  the  large  size  of  the  family  predisposes  to  disabling  sickness,  or  at 
any  rate  is  correlated  with  it.  This  association  is,  of  course,  not  a  direct 
one ;  it  is  mediated  by  the  consequences  almost  invariably  bound  up  with 
large  families — lowered  standards  of  living,  malijutrition,  over-crowding, 
underheating  and.  so  forth.  The  vicious  circle  in  this  situation  may  be 
analyzed  in  some  detail.  An  increasing  family,  if  earnings  remain 
stationary,  automatically  tends  to  lower  the  standard  of  living.  When 
once  the  family  income  is  sufficient  to  meet  a  budget  adequate  to  provide 
for  the  existence  minimum,  malnutrition,  overcrowding^  underheating, 
and  deficient  clothing,  severally,  or  in  combination,  are  inevitable.  This 
lowered  level  of  living  depletes  the  physical  vitality  and  diminishes  the 
physiological  resistance  to  disease.  Consequent  disabling  sickness  of  the 
wage-earner,  more  often  than  not  accompanied  by  illnesses  of  members 
of  the  family,  entails  loss  of  wages,  and  the  costs  of  medical  treatment. 
The  desperate  situation  of  the  wage-earning  family  now  dependent  as 
a  result  of  this  process  of  economic  degradation,  is  graphically  described 
in  the  following  instances. 

Case  12.  Normal  hreadwinner^  other  chronic  disablmg  sicTcness 
of  fifty-two  weeks. — Mr.  and  Mrs.  N.  have  seven  children,  all  girls. 
The  oldest  is  only  twelve  years  old,  the  youngest  nine  months.  Mr. 
N".  has  been  working  for  a  car  shop  during  a  period  of  five  years.  He 
had  been  doing  heavy  work,  and  soon  developed  heart  trouble. 
Later  his  physican  forbade  him  to  work,  but  having  a  wife  and 
children  to  support  he  kept  his  position  until  he  was  obliged  to 
leave  and  apply  for  admission  to  the  Cook  County  Hospital.  He 
is  not  able  to  work,  and  is  at  present  at  home  hoping  for  a  time 
when  he  will  be  able  to  work  again.  His  wife  is  not  able  to  work- 
since  the  youngest  of  the  children  is  only  nine  months  old.     The 


285 

County  Agent  provides  the  family  with  groceries  and  other  necessi- 
ties, while  the  United  Charities  is  paying  their  rent  and  also  eight 
dollars  a  week  for  living  expenses.  The  man  and  woman  are,  how- 
ever, in  very  low  spirits  seeing  no  way  out  of  the  situation.  To  get 
well  the  man  would  need  to  spend  several  months  at  least  on 
some  farm  having  plenty  of  fresh  air  and  good  meals.  Both  the 
father  and  mother  say  that  they  keep  on  struggling  only  for  the 
sake  of  the  children. 

The  next  case  shows  the  difficulty  of  even  an  industrious  and  home- 
caring  man  to  provide  for  a  wife  and  eight  children.        ' 

Case  13.  Normal  hreadivinner,  acute  illness. — There  are  eight 
children  in  this  Polish  family,  ranging  in  age  from  boy  of  ten  to  a 
nine-months  baby.  The  father  is  thirty-seven  and  the  mother 
thirty-one.  He  earns  $15  a  week  as  foundryman,  but  lost  three 
weeks  wages  because  of  stomach  trouble.  Last  year  the  total  family 
income  was  only  $745  which  is  only  fifty-four  per  cent  of  the  con- 
servative amount  fixed  by  our  conservative  charity  budget  as  neces- 
sary to  provide  for  the  necessaries  of  existence.  The  children 
have  been  in  bad  need  of  clothing  as  wife  is  unable  to  manage  on  the 
husband's  wages.  He  is  a  sober  man  and  always  turns  his  pay  en- 
velope unopened  over  to  his  wife.  However,  the  family  is  Just 
kept  from  starvation.  Only  the  children  are  insured  for  five  cents 
each  a  week. 

(5)   Sickness  as  a  Cause  of  Poverty.     A  Study  in  Economic  Strain  and 
Lowered  Standards  of  Living  of  2,108  Wage^earning  Families. 

The  investigations  of  Warner,  Devine  and  the  Immigration  Com- 
mission are  studies  of  dependency,  not  of  poverty.  The  analysis  of  the 
reports  of  Illinois  charity  organization  societies,  of  three  Chicago  Char- 
ties,  and  of  the  628  charity  families  in  the  Family  Study  were  con- 
cerned with  dependents  rather  than  with  the  broader  group  of  the  poor. 
While  it  is  not  to  be  gainsaid  that  the  facts  of  dependency  throw  light 
on  the  conditions  and  causes  of  poverty,  it  is  not  sufficient  merely  to 
apply  without  modification  to  the  group  of  the  poor  the  findings  of  the 
study  of  the  dependent. 

The  distinction  between  dependency  and  poverty  has  already  been 
made.^*^  The  dependent  are  those  supported  temporarily  or  perman- 
ently by  State  or  private  charity.  The  poor  are  those  who  live  below  a 
minimum  standard  of  physical  existence.  Charitable  aid  as  the  cri- 
terion of  dependency  is  easily  applied.  Existence  below  a  physiological 
minimum  as  the  criterion  of  poverty  is  not  only  more  difficult  to  de- 
termine, but  is  less  objective,  and,  in  consequence,  less  readily-  agreed 
upon  by  students  of  the  problem.  In  fixing  upon  an  income  necessary 
for  the  bare  necessaries  of  life,  but  relative  to  the  composition  of  the 
family  by  number,  sex,  age,  and  employment,  it  was  decided  to  employ  a 
conservative  budget  already  in  use  by  Chicago's  charitable  agencies. 
As  explained  in  detail  i^  the  introduction^^  to  the  Family  Study,  the 
sum  below  which  an  income  would  be  regarded  as  deficient  for  a  family 


^  See  p.  184. 
"See  p.   185-88. 


286 

of  father,  mother  and  three  children,  not  over  fourteen  years  of  age  was 
fixed  at  $850.  From  the  standpoint  of  this  study  "the  poor"  in  our 
2,708  wage-earning  families  living  in  the  blocks  surveyed  in  the  Family 
Study  are  those  whose  actual  economic  status  for  the  year  1917-18  was 
determined  as  Class  C.  The  assignment  of  families  to  Class  C  as  "the 
poor"  is  from  the  standpoint  of  their  income  only,  not  from  that  of 
actual  living  conditions. 

The  point  may  be  made  as  a  concrete  fact  of  social  life  that  poverty  is 
not  to  be  determined  in  the  arbitrary  w^ay  just  described,  that  poverty 
is  relative,  and  is  more  naturally  represented  by  the  acute  distress  caused 
by  dow^nward  revision  in  a  customary  standard  of  living.  It  is  recog- 
nized that  poverty  may  be  regarded  from  both  viewpoints,  either  of  an 
income  inadequate  to  provide  for  the  bare  necessities  of  life  or  as  an 
abrupt  reduction  in  income  requiring  radical  changes  in  habits  of  ex- 
penditure. For  this  reason  the  analysis  of  the  relation  of  sickness  to 
poverty  is  taken  up  under  two  heads : 

(a)  Sickness  as  a  cause  of  lowered  standards  of  living. 

(b)  Sickness  as  a  cause  of  poverty  defined  as  income  below  stand- 
ards of  a  subsistence  budget. 

(a)   Sickness  as  a  Cause  of  Lowered  Standards  of  Living. 

A  sudden  shift  such  as  that  caused  by  sickness,  unemployment  or 
other  misfortune,  from  an  accustomed  to  a  lower  economic  level,  always 
constitutes  a  crisis,  requiring  adjustments  in  mental  attitudes  and  habits 
of  life.  Deprivation,  if  not  distress,  is  inevitably  involved.  The  extent 
and  the  nature  of  the  changes  caused  by  disabling  sickness  are  clearly 
seen  in  the  relation  of  illness  to  change  in  economic  status,  to  the  high 
costs  of  sickness,  and  to  family  deficits. 

In  313,  or  13.2  per  cent,  of  the  2,598  wage-earning  families,  costs 
of  sickness  in  lost  wages  and  in  direct  outlays  caused  a  shift  to  a  lower 
economic  status  during  the  year.  This  change  was  measured  by  de- 
termining for  the  year  of  the  study  both  the  normal  economic  status 
(actual  income  increased  by  lost  wages)  and  the  actual  economic  status 
(actual  income  decreased  by  direct  outlays  for  sickness).  Of  the  1,022 
families  in  Class  W,  129  or  12.6  per  cent  experienced  a  descent  in  eco- 
nomic-level, 112  making  one  shift  to  Class  A,  15  two  shifts  to  Class  B, 
and  2  three  shifts  to  Class  C.  Of  the  665  families  in  Class  A,  133  or 
20.0  per  cent  were  shifted  downward  by  sickness,  121  making  one  change 
to  Class  B,  and  12  two  changes  to  Class  C.  Of  the  631  families  in  Class 
B,  81  or  12.8  per  cent  descended  one  level  to  Class  C. 

In  any  use  of  these  shifts  in  economic  status  it  must  be  understood^- 
that  although  the  line  of  division  between  Classes  "C"  and  "B"  was 
determined  by  the  income  necessary  to  provide  for  a  charity  or  subsist- 
ence budget,  the  dividing  lines  between  Classes  B  and  A  and  between  A 
and  W  are  arbitrary.  Accordingly  in  many  cases  large  sickness  costs 
may  occasion  no  change  in  economic  status  (taking  place  within  the 
limits  of  an  economic  class),  while  a  relatively  small  sickness  cost  in  a 
family  just  above  the  dividing  line  between  two  economic  classes  will  be 

^"^  See  Introduction,  pp.  185-90  for  a  detailed  explanation  of  method  of  arriving 
at  the  different  groups  by  economic  status. 


387 


sufficient  to  depress  it  into  the  lower  status.     Yet,  on  the  whole,  sick- 
ness costs  occasioning  shifts  in  status  were  of  considerable  size. 

In  relatively  few  cases  was  the  downward  shift  the  result  of  com- 
paratively small  sickness  costs.  Only  40  of  these  families  or  11.7  per 
cent  had  sickness  costs  of  less  than  $50  (averaging  $26.38)  ;  55  families 
or  16.0  per  cent  had  sickness  costs  of  $50  but  less  than  $100  (averaging 
$76.36)  ;  63  families  or  18.4  per  cent  had  sickness  costs  of  $100  but  less 
than  $150  (averaging  $122.46)  ;  36  families  or  10.5  per  cent  had  sick- 
ness costs  of  $150  but  less  than  $200  (averaging  $179.67) ;  48  families  . 
or  14.0  per  cent  had  sickness  costs  of  $200  but  less  than  $300  (averaging 
$242.58)  ;  35  families  or  10.2  per  cent  had  sickness  costs  of  $300  but  less 
than  $400 (averaging  $343.71)  ;  23  families,  or  6.7  per  cent  had  sickness 
costs  of  $400  but  less  than  $500  (averaging  $438)  ;  43  families  or  12.5 
per  cent  had  sickness  costs  of  $500  or  over,  averaging  $681.91. 

The  following  table  gives  the  grouping  of  wage-earning  families 
excluding  Class  D  by  both  '^normal"  and  "actual  economic  status." 


Normal  economic  status 
(income  augmented  by 
wages  lost  in  1917-18). 

Actual  economic  status 

(actual  income  less  costs 

of  medical  treatment). 

Number. 

Per  cent. 

Number. 

Per  cent. 

Total  wage-earning  families 

2,598 

100.0 

2,598 

100.0 

Reporting  completely — 

Class  W  families  with  liberal  income 

1,022 
665 
631 

280 

39.3 
25.6 
24.3 
10.8 

893 
644 
686 
375 

34.4 

Class  A  families  with  moderate  income 

24.8 

Class  B  families  with  meager  income 

Class  C  families  with  deficient  income 

26.4 
14.4 

As  the  outcome  of  the  343  shifts,  we  find  that  the  difference  be- 
tween normal  and  actual  economic  status  is  inconsiderable  in  Classes 
A  and  B,  but  considerable  in  Classes  W  and  C. 

Other  facts  concerning  the  relation  of  disabling  sickness  to  change 
of  economic  status  are  desirable.     Data  are  available  upon  two  points: 

(a)  first,  sickness  losses  causing  change  in  economic  status  classified 
by  the  member  of  the  family  whose  sickness  was  largely  responsible,  and 

(b)  secondly,  the  types  of  illness  chiefly  responsible  for  shift  to  a  lower 
economic  level.  The  following  table  was  prepared  to  show  the  change 
in  economic  status  occasioned  by  the  disabling  illness  of  particular 
members  of  the  family.  In  every  case  the  illness  of  the  assigned  person 
entered  definitely  into  the  loss  that  occasioned  the  shift  in  economic 
level.  In  cases  where  disabling  illness  of  more  than  one  person  is  re- 
ported the  disabling  sicknesses  of  two  or  more  members  of  the  family 
were  held  jointly  responsible. 


288 


Particular  member  or  members  of  family  whose  disabling  illness  was  the 
cause  of  shift  to  lower  economic  class. 


Number  of  shifts 
in  economic 

status 

attributed  to 

particular 

member  or 

members  of 

family. 


Normal  bread  winner  (father)  only 

Mother  only '. 

Wage-earning  child  or  children 

Unemployed  child  or  children 

Dependent  relative 

Normal  bread  winner  (father)  and  mother 

Normal  bread  winner  (father)  and  a  wage-earning  child  or  children 

Normal  bread  winner  (father)  and  unemployed  child  or  children 

Normal  bread  winner  (father),  mother,  and  unemployed  child  or  children 

Normal  bread  winner  (father),  mother,  and  wage-earning  child 

Mother  and  wage-earning  child  or  children 

Mother  and  unemployed  child  or  children 

Total 


165 

74 

22 

21 

3 

24 

11 

2 

5 

1 

2 

13 


343 


This  table  shows  that  the  illness  of  the  father  as  the  normal  bread- 
winner was  assigned  as  full  cause  of  the  shift  to  a  lower  group  in  165 
out  of  343  cases,  and  entered  in  43  other  cases  in  conjunction  with  ill- 
ness of  other  members  of  the  family. 

A  comparison  similar  to  the  last  was  prepared  to  indicate  the  rela- 
tive weight  to  be  given  to  different  types  of  sickness  in  the  343  cases 
of  change  to  a  lower  economic  class.  Since  in  certain  cases  of  shift 
the  sickness  of  two  or  more  members  of  the  family  was  held  responsible, 
it  was  necessary  to  apportion  responsibility  in  certain  cases  among  two 
or  more  disabling  illnesses,  considering  each  case  as  a  unit. 


Type  of  disabiling  illness  causing  shift  to  lower  economic  class. 


Type  of  disability  held  respon- 
sible for  shift  to  lower 
economic  status. 


Number  of 

unit  cases. 

Per  cent. 

11.0 

3.2 

138.0 

40.2 

111.0 

■    32.4 

31.0 

9.0 

30.  .5 

8.9 

6.5 

1:9 

2.0 

.6 

1.0 

.3 

3.5 

1.0 

8.5 



2.5 

Tuberculosis 

Chronic  diseases  other  than  tuberculosis . . . 

Acute  illnesses 

Confinement 

Accidents 

Physical  defect 

Insanity 

Old  age 

No  disabling  sickness,  but  cost  of  medicine 
Nature  of  illness,  not  reported 

Total 


343. 0 


100.0 


The  low  proportion  of  cases  of  tuberculosis,  strikingly  smaller  than 
the  percentage  reported  by  the  United  Charities  and  Cook  County 
Agent  as  problems  or  causes  of  dependency,  is,  in  part,  to  be  explained 
by  the  assumption  that  families,  in  many  cases,  did  not  report  the  ail- 
ment as  tuberculosis.  The  larger  proportion  of  chronic  as  compared 
with  acute  illnesses  is  due  to  the  disproportion  of  chronic  acute  ail- 
ments in  the  cases  where  sickness  of  mothers  was  held  responsible  for 


289 

the  shift  to  a  lower  economic  class.  In  only  3  out  of  the  343  cases  did 
the  disability^  held  responsible  for  the  shift  continue  fifty-two  weeks. 

While  acute  and  chronic  diseases  are  considered  responsible  for 
nearly  three-fourths  of  the  shifts,  attention  should  be  given  to  the 
proportion  of  weight  assigned  to  confinement  as  leading  to  lowered 
economic  status.  In  26  cases  the  entire  and  in  11  additional  cases  the 
partial  reason  for  the  shift  was  found  in  the  expenses  connected  with 
maternity. 

A  less  artificial  and  arbitrary  criterion  of  lowered  standards  of 
living  than  change  in  economic  status  is  afforded  by  a  study  of  sickness 
losses  and  of  family  deficits  resulting  from  illness.  The  average  cost 
of  sickness  of  wage-earning  families  reporting  was  $97.98.  A  loss  of 
approximately  $100  per  family  is  large  enough  to  place  a  severe  strain 
upon  the  great  majority  of  wage-earning  families.  From  the  stand- 
point of  lowered  standards  of  living,  deviations  from  the  average^  and 
not  the  average  sickness  cost,  are  significant.  Important  also  is  capacity 
to  bear  sickness  losses  as  indicated  in  our  study  by  the  grouping  of 
families  according  to  economic  status.  The  following  table  indicates 
the  distribution  of  sickness  costs  above  the  average  among  the  wage- 
earning  families  in  the  blocks  grouped  by  economic  status : 


Sickness  costs  in  excess  of- 


Percentage  of  families  reporting  sickness  costs 
in  excess  of  SIOO. 


All. 


Class  A. 


Class  B. 


Class  C. 


$100 
$200 
$300 
$400 
$500 


30.4 

31.3 

26.6 

21.1 

16.6 

12.3 

9.2 

11.2 

7.0 

5.4 

8.0 

4.1 

3.4 

3.6 

2.7 

34.1 

17.9 

8.4 

5.0 

3.4 


Interpreting  this  table  in  the  light  of  facts  presented  earlier  in 
this  report,  we  find:  (1)  although  the  proportion  of  sickness  is  higher 
with  the  poor  than  with  those  above  the  subsistence  level  (percentage  of 
families  with  disabling  illness,  76.0,  73.0  and  63.4  for  Classes  C,  B,  and 
/^53  respectively),  the  burden  of  sickness  losses,  as  already  determined, 
is  much  greater  in  the  case  of  poor  families  than  of  those  in  meager  and 
"better  off''  circumstances  (sickness  cost  relative  to  total  family  income 
15.6  per  cent  for  "C,"  8.4  per  cent  for  "B,''  and  7.5  per  cent  for  "A'' 
families)  ;  (2)  that  as  shown  by  this  table  the  proportion  of  families 
in  poverty  with  sickness  costs  in  excess  of  $100  (greater  than  the  aver- 
age for  all  families  reporting,  or  $97.98)  is  somewhat  greater  than  the 
per  cent  of  families  with  higher  incomes,  and  considerably  above  that 
of  families  with  meager  incomes  (34.1  per  cent,  31.3  per  cent,  and 
26.6  per  cent  for  families  in  Classes  C,  A,  and  B,  respectively.) 

The  fact  that  3  out  of  every  10  families  reporting  state  sickness 
losses  in  excess  of  $100  for  the  year  suggests  the  degree  of  economic 
pressure   placed   upon    a   large    proportion    of   wage-earning   families. 

=3  See  p.  203. 


—19  H  I 


290 


Smaller  sickness  costs  may  perhaps  often  be  met  with  little  or  no  per- 
ceptible lowering  of  the  standard  of  living.  Large  illness  losses  fre- 
quently compel  wage-earning  families,  whether  with  or  without  the  small 
protection  of  existing  health  insurance,  to  close  the  year  with  a  deficit. 

A  deficit  at  the  end  of  the  year  even  better  than  sickness  costs  is 
indicative  of  economic  stress  and  strain.  Important  facts  in  regard 
to  deficits — the  -  number  and  proportion  of  families  failing  to  make 
ends  meet,  and  the  percentage  of  deficits  of  income  are  shown  here 
b}^  economic  status  for  the  block,  nursing  service  and  oharity  families 


54 


Economic  status. 


Number 

Number 

of 

Number 

Per  cent 

reporting 

Amount 

Amoimt 

families 

with 

with 

amount 

of 

of 

with 

deficit. 

deficit. 

of 

mcome. 

deficit. 

sickTiess. 

mcome. 

Per  cent 

deficit 

of  income. 


Block  study 

Class  A 

Class  B 

Class  C 

Nursing  service  study 

Class  A 

Class  B 

Class  C 

Charity  study 


1,744 

290 

16.6 

247 

251,591 

38,213 

1,070 
461 
213 

102 
96 
92 

9.5 
20.8 
43.2 

90 

84 
73 

122,543 
83,800 
45,248 

14,304 

8,733 

15,176 

265 

110 

41.5 

97 

120,604 

12,564 

127 
90 
48 

42 
35 
33 

33.1 
38.9 
68.8 

38 
32 
27 

59,801 
36,828 
23,975 

5,959 
3,448 
3,155 

554 

502 

90.6 

409 

228,362 

100,063 

15.2 


11.6 
10.4 
33.5 


10.4 


10.0 

9.4 

13.2 


43.8 


This  table  shows,  first  of  all,  the  relatively  large  number  of 
families  with  deficits  in  the  charity  and  nursing  service  groups.  This 
is,  how^ever,  only  to  be  expected  for  they  are  selected  groups.  A  sig- 
nificant fact  is  that  while  only  1  in  11  (9.5  per  cent)  of  the  Class  A 
and  only  1  in  5  (20.8  per  cent)  of  the  Class  B  families  in  the  block 
study  had  deficits,  the  corresponding  figure  for  Class  C  families  was 
more  than  2  in  5  (43.2  per  cent).  Another  significant  fact  is  that  the 
deficits  for  C  families  were  relatively  much  larger  than  the  deficits  of 
families  in  Classes  A  and  B.  The  deficits  of  those  in  the  first  (Class 
C)  group  were  33.5  per  cent  of  their  incomes;  of  those  in  Class  A,  11.6 
per  cent;  of  those  in  Class  B,  10.4  per  cent.  These  same  variations, 
although  to  a  smaller  extent,  are  shown  by  the  percentages  presented 
for  the  nursing  service  families.  That  two-fifths  of  the  wage-earning 
families  in  poverty  had  last  year,  in  connection  with  sickness,  deficits 
averaging  one-third  of  their  income  suggests  the  pressure  of  sickness  in 
pushing  the  poor  into  dependency. 

Naturally  the  question  arises  as  to  how  far  sickness  was  the  cause 
of  the  deficits  shown.     A  partial  answer  is  given  in  the  data  collected. 

One  fact  shown  is  that  the  average  sickness  costs  of  families  with 
deficits  was  much  larger  than  the  average  for  the  entire  group  studied. 
Thus,  the  average  of  sickness  costs  for  the  block  wage-earning  families 
with  deficits  was  $183.09  as  against  an  average  of  $97.98  for  the  1,667 
reporting  completely  the  data  desired;  that  of  the  nursing  service 
families  with  deficits,  $214.79,  as  against  $136.72  for  the  larger  num- 
ber;  that  of  the  charity  families  with  deficits  for  the  year   (including 

^  See  also   Table   30,   p.    294. 


291 

nearly  all  of  course),  $274.63  as  against  $235.33  for  the  entire  number. 
But  after  all  what  is  most  desired  is  a  direct  comparison  of  the  amount 
of  deficit  and  the  sickness  costs  in  lost  wages  and  direct  outlays  in  each 
case  investigated.  Making  such  a  comparison  for  83  A  families  in  the 
block  studies  with  sickness  and  deficits  and  for  whom  all  data  required 
could  be  obtained,  56  had  sickness  costs  exceeding  their  deficits,  26  had 
deficits  exceeding  their  sickness  costs,  while  in  one  case  the  deficit  and 
sickness  costs  were  reported  as  the  same.  Taking  73  B  families  in  the 
same  study,  41  had  sickness  costs  in  excess  of  tlieir  deficits,  while  32  had 
deficits  in.  excess  of  their  sickness  costs.  Taking  66  C  families,  in  34 
cases  the  sickness  costs  were  in  excess  of  the  deficits  while  in  32  cases 
the  contrary  was  true.  Comparing  averages  where  sickness  costs  ex- 
ceeded deficits,  the  former  were  $345.41,  the  latter  $104.23  for  A 
families,  $195.29  and  $67.02  for  B  families,  and  $220.59  and  $84.26 
for  C  families.  Comparing  averages  where  deficits  exceeded  sickness 
costs,  we  have  $303.69  as  against  $110.15,  $165.88  as  against  $44.81, 
and  $255.88  as  against  $46.06 — the  averages  of  deficits  and  sickness 
costs  for  A,  B  and  C  families  respectively. 

These  data  merely  put  into  statistical  form  what  every  one  knows, 
viz.,  that  sickness  is  a  very  important  but  not  the  only  cause  of  family 
deficits. 

That  1  in  6  of  all  the  wage-earning  families  with  sickness  in  the 
blocks  studied  had  last  year  lost  wages  and  direct  outlays  caused  by 
illness  avel-aging  $183.09  does  not  tell  the  whole  story.  The  data  thus 
far  presented  must  be  supplemented  by  other  information,  for  sickness 
costs  are  more  or  less  frequently  accompanied  by  exhaustion  of  savings, 
by  retrenchment  and  deprivation,  by  incurring  of  debt,  by  gainful  em- 
ployment of  wife  or  older  children,  by  charity  and  dependency.  In 
practically  every  case  of  illness  the  cost  of  medical  treatment  had  not 
been  foreseen  or  calculated  upon  as  part  of  the  family .  expenditure. 
All  of  the  1,744  families,  approximately  two-thirds  of  the  entire  gi-oup 
of  2,598  families  who  reported  disabling  sickness,  apprehended  if  they 
did  not  actually  experience  the  menace  of  an  imperiled  standard  of 
living. 

The  exhaustion  of  savings  to  meet  the  losses  of  sickness  would  not, 
from  a  purely  economic  standpoint,  be  considered  a  change  in  ihe 
standard  of  living.  From  the  point  of  view  of  family  security  and 
social  attitudes,  however,  it  generally  involves  a  descent  in  the  scale  of 
social  life.  In  a  considerable  number  of  our  charity  families  use  of 
savings  preceded  appeal  for  aid.  In  the  families  in  the  blocks  thirty- 
seven  report  drawing  upon  savings  to  meet  costs  of  illness. 

Retrenchment  and  deprivation  almost  invariably  accompany  and 
follow  sickness.  Illness  in  most  cases  means  unforseen  and  increased 
expenditure  often  concurrent  with  a  reduction  in  income  through  loss 
of  wages.  The  emergency  in  the  family  economy  must  be  met.  Among 
all  independent  wage-earning  families  the  most  common  method  is 
retrenchment  and  deprivation.  Not  infrequently  the  retrenchment  is  in 
medical  service  requisite  for  the  treatment  of  the  disease. 

Case    14.  Retrenchment   and   deprivation. — A    young*   Polish- 
American  couple  with  a  child  three  years  of  age,  live  in  a  rear 


292 

apartment  of  three  rooms  renting  for  $6  a  month.  Last  winter 
when  the  father  was  home  ill  with  rheumatism  the  mother  was 
employed  two  weeks  at  piece  work,  earning  about  $6  a  week.  This 
was  the  only  time  she  had  worked  since  her  marriage.  They  wanted 
to  have  a  doctor  for  him,  but  "it  cost  too  much''  and  "he  got  well 
without  it." 

Several  striking  illustrations  of  deprivation  of  medical  service 
might  be  presented.  There  is  the  woman,  a  Jewish  immigrant  from 
Eussia,  who  because  of  retrenchment  due  to  illness  of  husband,  was 
compelled  to  give  birth  to  her  child  at  home  instead  of  at  the  hospital 
as  had  been  arranged.  In  a  German  Polish  family,  because  of  the 
disabling  sickness  of  the  father,  there  was  so  little  money  that  the 
mother  had  neither  physician  nor  midwife  at  the  time  of  childbirth. 

Most  often  retrenchment  takes  the  form  of  deprivation  in  needed 
food,  clothing  and  heat.  More  than  one  family  reported  to  our  investi- 
gators that  as  a  result  of  sickness  of  wage-earner  "they  lived  on  black 
coffee  and  bread''  and  in  one  instance  our  visitor  found  that  in  a  family 
where  the  breadwinner  had  been  disabled  for  twenty-five  weeks  the 
noon-day  meal  for  father,  mother  and  three  children,  seven,  five  and 
three  years  old,  consisted  of  bread  and  beer. 

A  special  form  of  retrenchment  is  the  change  in  standard  of  living 
involved  in  moving  to  cheaper  quarters.  Retrenchment  in  food  and 
warmth,  even  in -clothes,  does  not  carry  with  it  the  sense  of  Social  defeat 
implied  in  the  act  of  moving  to  a  poorer  dwelling.  An  agent  of  the 
Commission  in  her  report  on  a  certain  block  commented  on  the  disgrace 
experienced  in  this  descent  in  social  status.  "An  interesting  situation 
was  revealed  in  the  case  of  the  few  Americans  in  the  block.  They  live 
in  the  poorest  and  cheapest  dwellings  on  the  street,  and  have  come  there 
apparently  to  hide  from  their  friends  until  their  circumstances  are 
bettered.  In  two  cases,  prolonged  sickness  was  the  drawback.  As  a 
rule,  the  Americans,  considering  themselves  superior,  do  not  mix  with 
their  neighbors." 

How  sickness  costs  may  compel  moving  to  a  cheaper  location  and 
the  possible  social  consequences  upon  childhood  is  well  indicated  in  the 
following  case: 

Case  15.  Retrenchment  and  deprivation.  Moving  to  cheaper 
quarters. — This  is  an  American  family  of  the  standard  budget  type, 
father,  mother  and  three  children.  This  mother  is  decidedly  an 
exceptional  woman.  She  told  the  visitor  that  three  years  ago  the 
family  lived  in  a  $20  flat  in  one  of  Chicago's  suburbs;  they  had 
plenty  of  space  and  there  was  fresh  air  for  the  children.  However, 
the  children  became  sick;  they  had  measles  together,  then  they 
caught  scarlet  fever,  and  no  sooner  were  thev  better  than  the  baby 
got  infantile  paralysis.  For  the  whole  year,  practicallv,  the  chil- 
dren were  ill,  and  the  doctor  bills  and  other  debts  increased  con- 
tmually.  The  father  worked  steadily,  but  by  the  time  the  children 
were  entirely  recovered,  the  family  was  badly  in  debt.  The  first 
thing  the  mother  did  was  to  move  to  this  $11  flat,  and  she  has 
scraped  and  economized  every  possible  way  during  the  last  two  years 


293 

to  get  out  of  debt.     She  says  it  is  only  the  last  two  months  that 
they  have  paid  up  every  penny  owed. 

Not  infrequently  moving  to  cheaper  quarters  denotes  moving  to 
houses  in  bad  condition.  AY  here  the  combination,  as  in  the  next  case, 
of  sickness,  loss  of  economic  productivity  and  of  bad  housing  occurs, 
the  family  has  reached  the  depths  of  destitution  and  degradation. 

Case  16.  Retrenchment  and  deprivation.     Moving  to  bad  hous- 
ing conditions. — This  family  of  father,  mother  and  five  children 
under  fourteen  years  of  age,  is  in  very  bad  circumstances.     Mr.  B. 
has  been  tuberculous  for  several  years,  and  within  the  last  year  has 
been  forced  to  go  to  the  Municipal  Tuberculosis  Sanitarium  for 
treatment,  thus  being  unable  to  contribute  to  the  support  of  the 
family.     Mrs.  B.  is  his  second  wife,  and  the  step-mother  of  the 
three  oldest  children.    For  some  time  she  was  not  allowed  to  work, 
owing  to  the  fact  that  her  children  needed  her  at  home.     However, 
she  managed  to  work  about  two  days  a  week,  for  about  half  of  the 
year,  earning  under  $100,  when  she  was  able  to  leave  the  children 
(those  not  going  to  school)   with  a  friendly  neighbor.     The  home 
to  which  the  family  w^as  forced  to  move  by  the  father's  sickness, 
is  a  sorry  sight,  situated  in  the  rear  of  another  house.     It  is  a  wooden 
structure,  and  could  easily  be  mistaken  for  a  common  woodshed. 
Directly  in  the  rear  of  this  house  is  a  railroad  track  upon  which 
.    the  oldest  son  goes  to  pick  up  stray  pieces  of  coal. 
With  retrenchment  and  deprivation,  sometimes  without  it,  comes 
debt.     The  resistance  of  wage-earning  families  against  going  into  debt 
is  strong.     Agents  for  the  Commission  quote  families  as  having  a  "horror 
of  debt,"^^  or  willing  "to  go  without  food  rather  than  go  into  debt.^'^^ 
Yet  many  families  were  forced  to  leave  bills  unpaid,  or  to  seek  loans  be- 
cause of  sickness.    Table  30  presents  an  analysis  of  deficits  of  the  wage- 
earning  families  with  sickness  in  the  block,  nursing  service  and  charity 
groups.     Of  the  1,744  block  families  with  sickness  in  Classes  A,  B    and    C 
290,  or  16.6  per  cent,  had  deficits  at  the  end  of  the  year  as  against  40,  or 
4.7  per  cent,  of  854  families^''  without  sickness  who  failed  to  make  ends 
meet.     Of  the  290  families  with  deficits,  104  left  bills  unpaid,  and  64 
made  loans,  and  the  remainder  drew  upon  savings,  used  principal  of 
insurance  received,  etc. 

Case  17.  Going  into  debt. — ^The  mother  and  sister  of  the  wife 
live  with  this  young  colored  couple,  who  have  no  children.  When 
the  husband  lost  ten  weeks  by  sickness,  the  wife  went  to  work.  Out 
of  her  earnings  she  was  able  to  pay  only  for  food,  oil,  light  and 
three  months  rent.  The  back  rent  was  gradually  paid  up  out  of  the 
earnings  of  the  husband  when  he  returned  to  work.  They  are  now 
square  with  the  world. 

As  long  as  the  credit  of  the  family  is  good  and  the  grocer,  landlord 
and  physician  do  not  press  for  payment,  as  often,  especially  where  there 
is  sickness  in  the  family,  they  are  willing  to  do,  the  family  is  able  to 
maintain  its  self-respect  and  confidence.  Occasionally,  however,  the 
chattel  mortgage  and  the  "loan  shark''  obtain  a  hold  upon  the  family. 

'K'U.  S.  I.   23. 

"G.   12. 

"  See  also  Summary  Table,  p.  199. 


294 


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Case  18.  Mortgage  on  furniture.^ — This  is  a  Jewish  family  of 
six  members:  father,  mother,  a  daughter  of  17,  a  son  of  16,  and 
two  girls  of  13  and  11.  When  the  husband  was  ill,  the  wife  was 
forced  to  mortgage  the  furniture,  including  the  piano.  This  debt 
of  $200  worries  the  mother  and  she  intends  to  get  some  sort  of 
light  work  in  order  to  help  pay  it  off.  The  two  older  children  both 
have  appendicitis  and  the  doctor  has  urged  an  operation,  but  the 
children  are  afraid  and  the  parents  cannot  afford  to  pay  for  opera- 
tions. The  mother  would  not  allow  them  to  go  to  a  dispensary. 
The  mother  has  had  several  operations  within  the  last  three  years, 
but  all  without  cost.  She  is  not  able  to  do  much  work.  The  two 
older  children  Avorked  for  a  time  in  the  summer,  but  will  return 
to  high  school  in  the  fall. 

When  the  wife  or  children  under  16,  or  older  children,  go  to  work 
because  of  illness  in  the  family,  the  standard  of  living  is  lowered  at 
still  another  point.  The  imminence,  if  not  the  actual  pressure  of  desti- 
tution, because  of  the  disabling  sickness  of  her  husband,  drives  the  wife 
to  work  to  prevent  or  lessen  deprivation.  Her  enforced  absence  from 
the  home  may  lead  to  loss  to  the  family  and  to  the  community.  In  74 
families  or  4.2  per  cent  of  1,744  wage-earning  families  in  the  block 
study  where  sickness  was  recorded,  the  wife  (39  cases),  or  children 
under  16  (19  cases),  or  older  children  (16  cases),  went  to  work  io 
^  supplement  the  family  income,  reduced  by  loss  of  wages  and  depleted 
by  sickness  expenditures. 

The  following  case  indicates  the  drain  upon  the  physical  strength 
of  the  wife  and  mother  by  reason  of  the  double  function  of  housewife 
and  breadwinner : 

Case  19.  Substitution  of  wife  for  disabled  husband  as  bread- 
u^nner. — -This  Polish  family  consists  of  four  members,  father, 
mother  and  two  children,  12  and  8  years  old.  The  father  is  a 
cement  worker  by  trade.  The  first  fifteen  weeks  of  the  year  he 
earned  30  cents  an  hour  or  $14.40  a  week.  Then  early  in  November 
he  caught  a  severe  cold  from  which  pneumonia  developed.  This 
laid  him  up  until  the  first  of  March.  Just  as  he  was  starting  to 
work  again,  he  feH  and  dislocated  his  shoulder,  which  kept  him  at 
home  another  month.  After  his  fall,  the  mother  took  a  "job^^  as 
dishwasher  in  a  restaurant  at  $8  a  week.  She  is  not  very  strong 
and  the  work  was  too  hard  for  her.  In  April  and  in  May  she  was 
at  home  two  weeks  at  a  time  with  colds.  The  last  of  March  the 
father,  whose  shoulder  had  still  not  entirely  recovered,  started  to 
w^ork  as  flagman  on  the  tracks  at  $15  a  week.  He  is  far  from  well 
and  has  had  to  stay  at  home  twice  this  summer  for  about  eight  days 
at  a  time.  He  never  remains  away  from  work  long  enough  to 
receive  any  sickness  benefit.  The  first  of  July  the  mother  gave 
up  her  work  at  the  restaurant  and  is  staying  at  home  now.  She  has 
decided  there  is  no  use  in  her.  trying  to  work  any  longer,  as  it  is 
altogether  too  hard  for  her.  About  four  months  ago,  the  family 
took  a  lodger,  who  pays  them  $3  a  month. 

As  indicated  in  the  last  family  history,  the  taking  in  of  a  lodger 
is  one  method  by  which  the  wife  increases  the  family  income  and  re- 


296 

mains  at  home.  Several  of  our  reports  refer  to  the  real  lowering  of 
standards  in  wage-earning  families  consequent  upon  the  presence  of  a 
roomer.  Overcrowding,  the  disturbance  of  the  privacy  of  the  home,  and 
even  the  disintegration  of  the  family  are  mentioned  as  results  of  letting 
a  room  to  a  lodger  as  a  method  of  meeting  the  costs  of  sickness. 

After  exhaustion  of  surplus,  where  one  exists,  after  retrenchment 
and  deprivation,  after  all  means  of  self-help,  such  as  the  going  to  work 
of  wife  or  older  child,  are  inadequate,  the  family  as  a  last  resort  appeals 
to  charity.  Fifty  of  the  2,708  wage-earning  families,  in  the  blocks  re- 
ceived relief  from  Chicago  charities  last  year,  44  of  them  in  connection 
with  sickness.  Elsewhere^^  in  this  report  the  social  degradation  involved 
in  dependency  has  been  described.  Wliile  individual  and  racial  atti- 
tudes in  regard  to  help  from  charity  differ,  the  average  Chicago  wage- 
earning  family  seems  to  prize  its  independence.  As  a  sturdy  Slovak 
woman  said,  "I  would  rather  work  hard  for  my  own  money  than  have 
to  beg  it  from  the  city." 

The  following  case,  while  perhaps  not  typical,  is  certainly  not 
exceptional  in  its  indication  of  the  attitude  of  families  toward  seeking 
and  receiving  aid  from  charities. 

Case  20.  Appeal  to  charity. — Mr.  D.  has  been  tuberculous  for 
more  than  a  year.     He  seemed  quite  reluctant  to  admit  that  he 
had  had  to  apply  for  aid.    When  he  was  out,  his  wife  told  me  that 
she  had  applied  to  the  charities  to  help  her  in  caring  for  Louise, 
her  daughter.    Louise  was  to  be  brought  home  from  the  Municipal 
Tuberculosis  Sanitarium  but  the  visiting  nurse  would  come  daily 
to  dress  her  side.     Mrs.  D.  seemed  grateful  for  help,  and  said  that 
she  could  not  manage  without  help.     The  Municipal  Tuberculosis 
Sanitarium  had  screened  their  porch  and  equipped  it  with  beds. 
Their  home  was  in  good  order  and  well  finished. 
Not  infrequently  families  are  found  where  sickness  had  ultimately 
resulted  in  personal,  economic  and  social  degradation.     Its  forms  are 
various :  permanently  lowered  physical  efficiency  of  the  person ;  reduced 
economic  capacity  of  the  wage-earner;  pauperization;  family  disinte- 
gration. 

From  the  analysis  of  shifts  in  economic  status,  of  sickness  costs, 
of  deficits  and  from  the  description  of  concrete  changes  in  the  economy 
of  family  life  the  conclusion  seems  unescapable  that  disabling  sickness 
yearly  causes  sharp  economic  distress  and  depressed  standards  of  living 
in  a  relatively  large  number  of  wage-earning  families  in  Chicago.  How 
large  this  proportion  is  may  be  gauged  in  some  degree  by  bringing  to- 
gether the  different  figures  already  presented. 

(1)  Of  the  2,598  wage-earning  families  343  or  1  in  8  (13.2  per  cent) 
or  approximately  1  in  5  (19.7  per  cent)  of  those  with  illness  during  the 
year  experienced  a  shift  to  a  lower  economic  level  because  of  sickness. 
In  the  great  majority  of  cases  this  resulted  from  substantial  losses. 

(2)  Family  sickness  costs  in  excess  of  one  hundred  dollars  were 
borne  by  3  out  of  10  families  reporting  completely. 

(3)  Approximately  1  in  6  families  with  sickness  (16.6  per  cent) 
had  deficits. 

^See  pp.  265-75. 


297 


(4)  A  large  proportion  of  families  with  sickness  in  Class  C  carried 
a  relatively  high  burden  in  sickness  costs  and  over  two-fifths  were  left 
at  the  end  of  the  year  with  deficits. 

The  family  readjustments  required  to  meet  sickness  losses,  difficult 
to  present  completely  by  statistical  data,  have  been  described  in  terms 
of  depletion  of  savings,  of  retrenchment  and  deprivation,  of  debt,  of 
child  and  woman  labor,  of  destitution  and  dependency,  of  physical  ineffi- 
ciency and  reduced  economic  power,  of  pauperization  and  family  dis- 
integration. A  brief  discussion  will  now  be  given  of  the  extent  to  which 
sickness  causes  poverty  defined  as  income  insufficient  to  meet  the  stand- 
ards of  a  subsistence  budget. 

(b)  Sickness  as  a  Cause  of  Poverty. 

Of  the  2,598  wage-earning  families  (excluding  Class  D)  in  the  41 
blocks  of  our  Family  Study  reporting  income,  375,  or  14.4  per  cent, 
were  assigned  according  to  actual  economic  status  to  Class  C,  or  the 
poverty  group.  These  families  with  deficient  incomes,  could  not,  no 
matter  how  sober  the  husband  nor  how  careful  a  housekeeper  the  wife, 
on  the  income  received  last  year  meet  the  requirements  of  the  subsistence 
budget,  nor,  presiimably,  maintain  a  minimum  standard  of  physical 
efficiencv. 

Ninety-five,  or  25.3  per  cent,  of  the  375  poor  families  were  in  Class 
C  because  of  disabling  sickness  during  the  year.  If  these  95  families 
had  been  safe-guarded,  by  whatever  means,  against  the  loss  of  wages 
and  the  costs  of  medical  treatment  consequent  upon  illness,  their  eco- 
nomic status  above  the  level  required  for  physical  efficiency  would  have 
been  maintained  and  one-fourth  of  the  poverty  in. these  Chicago  blocks 
would  have  been  eliminated. 

An  analysis  of  the  normal  economic  status  of  the  95  families  who 
were  shifted  by  disabling  sickness  to  Class  C  or  the  poverty  group  with 
income  insufficient  to  meet  the  standards  of  a  subsistence  budget  dis- 
closes significant  details,  as  indicated  by  the  following  table : 


Normal  economic  status. 

Number 

of 
families. 

r 

Families  shifted  from 

Classes  W,  A,  and  B 

to  Class  C  because 

of  sickness  costs. 

Number. 

Percent. 

Class  W  with  liberal  incomes 

1,022 
665 
631 

2 
12 
81 

.2 

Class  A  with  moderate  incomes 

1.8 

Class  B  with  meager  incomes 

12.8 

Of  course  these  shifts  have  little  significance  unless  supported  by 
the  sickness  costs  involved,  for  81  of  the  95  were  from  Class  "B"  to  Class 
"C^^  where  insignificant  sums  might  account  for  the  change  from  the  one 
group  to  the  other.  The  fact  is,  however,  that  in  only  15  cases  of  the 
95  were  the  costs  less  than  $50,  the  average  for  the  15  being  $27.43.  As 
against  these  15,  there  were  13  with  costs  of  $50  but  less  than  $100, 
averaging  $76;  18  with  costs  of  $100  but  less  than  $150,  averaging 
$118.39;  8  with  costs  of  $150  but  less  than  $200,  averaging  $177.75; 


398 

16  with  costs  of  $200  but  less  than  $300,  averaging  $243;  7  with  costs 
of  $300  but  less  than  $400,  averaging  $326.43 ;  5  with  costs  of  $400  but 
less  than  $500,  averaging  $452.60;  and  13  with  costs  in  excess  of  $500, 
averaging  $653.92.  In  more  than  five  cases  in  six  the  sickness  costs  which 
resulted  in  the  placing  of  these  families  in  the  poverty  group  were  sub- 
stantial sums,  and  in  the  majority  of  the  cases  where  the  amounts  were 
small  absolutely,  they  cannot  be  said  to  have  been  unimportant  to  the 
families  concerned. 

These  statistics  but  reinforce  all  conclusions  that  have  been  obtained 
from  the  different  parts  of  the  investigation.  The  incidence  of  sickness, 
its  duration  and  costs,  its  results  in  the  lowering  of  standards^  its 
poverty  and  dependency  risks  all  fall  most  heavily  upon  families  of  lower 
economic  status  in  the  wage-earning  group. 

A  brief  resume  of  the  chief  conclusions  of  the  section  on  "Sickness 
as  a  Cause  of  Poverty"  follows : 

1.  The  conflicting  estimates  of  the  weight  of  sickness  as  a  factor  in 
dependency  in  the  literature  of  research  were  found  to  be  due  to  the 
absence  of  a  common  basis  of  comparison.  By  supplying  this  defect, 
it  was  found  that  Warner,  Devine  and  the  Immigration  Commission  are 
agreed  in  ascribing  to  disabling  illness  one-fourth  of  all  reported  causes 
or  conditions  of  dependency. 

2.  The  reports  of  eight  charity  organization  societies  outside  of 
Chicago  attribute  to  sickness  chief  responsibility  in  upward  of  one-third 
of  the  cases  seeking  relief  in  the  year  1917-18. 

3.  On  the  basis  of  a  study  of  the  experience  of  charitable  agencies 
in  Chicago  (covering  eight  years),  sickness  was  charged  with  one-third 
to  one-half  of  all  the  causes  or  problems  entering  into  dependency.  The 
higher  dependency  ratio  assigned  to  sickness  in  Chicago  than  obtained 
from  the  literature  of  the  subject  was  found  to  be  due  to  the  extensive 
unemployment  during  the  period  covered  by  the  earlier  investigations. 

4.  An  intensive  study  by  the  Commission  of  628  charity  families 
visited  in  the  Family  Study  indicated  that  the  majority  of  these  families 
had  been  economically  independent  prior  to  disabling  illness,  that  the 
dependency  risk  due  to  sickness  varied  directly  with  the  lower  economic 
status  of  the  family,  and  that  chronic  diseases  including  tuberculosis 
were  responsible  for  two-fifths  to  one-half  of  all  dependency  resulting 
from  physical  disability. 

5.  In  the  investigation  of  2,598  w^age-earning  families  (excluding 
Class  D)  in  the  block  study,  it  was  found  that  sickness  caused  a  change 
of  economic  status  in  343  families  or  more  than  one-eighth  of  the  total 
number  or  approximately  one-fifth  of  the  families  with  sickness.  It 
was  found  that  lowered  standards  of  living,  apart  from  change  in  eco- 
nomic status,  due  to  illness  could  be  measured  by  deficits  and  variations 
in  sickness  costs  and  were  manifested  in  savings  used,  in  retrenchment 
and  deprivation,  in  debts  to  physican,  landlord  and  grocer,  in  loans  from 
friends  and  commercial  agencies,  in  destitution  and  dependency,  in  de- 
creased physical  capacity,  and  diminished  earning  ability.  Finally,  it 
was  found  that  one-fourth  of  the  poverty  in  Chicago  in  1917-18  in  the 
wage-earning  families  of  the  block  study,  was  accounted  for  by  the  loss 
of  wages  and  sickness  costs  involved  in  disabling  illness. 


299 

This  review  of  the  interrelation  of  sickness  to  poverty  and  de- 
pendency indicates  that  a  constant  and  more  or  less  definite  fraction  of 
poverty  and  dependency  is  to  be  charged  to  the  disabling  sickness  of  the 
wage-earner  and  the  members  of  his  family. 

VI.  HEALTH  INSUEAN^CE  AS  A  SOLUTION. 

In  the  preceding  sections  the  problem  of  sickness  has  been  analyzed. 
Data  bearing  upon  its  duration,  its  costs,  the  care  of  the  sick,  and  exist- 
ing protection  against  its  risks  have  been  offered  for  the  block,^^  nursing 
service*^^  and  charity^^  families.  An  intensive  study  has  been  made  of 
tlie  causal  interrelations^^  between  sickness  and  poverty  and  dependency. 
Xothing  at  all  has  been  said  about  a  solution  for  the  problem. 

The  question  naturally  arises,  what  difference  would  an  organized 
system  of  health  insurance  have  made  ?  Health  insurance  of  course  has 
many  aspects.  Some  of  these  are  not  revealed  by  such  investigations  as 
have  been  made  of  wage-earning  families  in  Chicago.  However,  the  data 
were  collected  and  tabulated  in  such  a  manner  that  the  question  raised 
could  be  partially  answered.  In  so  far  as  the  data  contain  an  answer  it  is 
set  forth  in  this  section  of  the  report. 

Several  health  insurance  measures  have  been  proposed  for  consider- 
ation and  'adoption.  The  best  known  of  these  is  the  "Model  Bill" 
drafted  by  a  committee  of  the  ^American  Association  for  Labor  Legis- 
lation. The  measure  most  actively  urged  for  adoption  has  been  drafted 
by  the  New  York  State  Federation  of  Labor.  This  measure  has  been 
accepted  as  the  fourth  edition  of  the  "Model  Bill."  Unfortunately  it  is 
impossible  to  apply  all  of  the  provisions  of  either  of  the  bills  mentioned 
to  our  data.  Under  the  circumstances  a  health  insurance  measure  is 
here  set  up  incorporating  "standards"  drawn  from  the  one  measure  or 
the  other  and  slio^ht  modifications  introduced  where  necessarv  in  order 
to  adopt  the  standards  to  the  purpose  in  view. 

The  assumed  system  of  health  insurance  here  applied  contains  the 
following  provisions : 

1.  All  employed  persons  engaged  in  manual  labor  in  the  State  and 
all  other  employed  persons  earning  $100  a  month  or  less  are  insured. 

2.  A  sickness  or  cash  benefit,  equal  to  two-thirds  {^^  2/3  per  cent) 
of  the  weekly  earnings  of  the  insured  person  is  paid  beginning  with  the 
eighth  day  of  disability  on  account  of  illness  or  non-industrial  accident. 
It  is  paid  only  during  continuance  of  disability,  and  is  not  paid  to  the 
same  person  for  a  period  of  over  twenty-six  weeks  in  any  consecutive 
twelve  months,  or  for  more  than  twentv-six  weeks  on  account  of  the 
same  case  of  disability. 

3.  All  necessary  medical,  surgical  and  nursing  service  is  furnished 
to  insured  persons  and  the  dependent  members  of  their  families  from  the 
first  day  of  sickness,  or  the  occurrence  of  the  non-industrial  accident, 
for  not  more  than  twenty-six  weeks  of  disability  in  any  consecutive 
twelve  months. 


=9  Sec  2.  The  Block   Study,   pp.    199-229. 

««Sec.   3.  The  Nursing   Study,   pp.    229-239. 

61  Sec.   4.  The    Charity    Study,    pp.    239-252. 

«2  Sec.   5.  Sickness  as  a  Cause  of  Poverty  and  Dependency,  pp.  252-99. 


*  300 

4.  Insured  persons  and  the  dependent  members  of  their  families 
are  supplied  with  all  necessary  medicines,  medical  and  surgical  supplies, 
dressings,  eye-glasses,  trusses,  crutches,  and  similar  appliances,  pre- 
scribed by  the  physican  or  surgeon. 

5.  A  burial  benefit  of  not  to  exceed  $100  is  provided  to  cover  the 
actual  cost  of  burial  of  an  insured  person. 

It  will  be  noted  that  neither  maternity  nor  dental  benefits  are  in- 
cluded in  the  measure  here  assumed.  Maternity  care  would,  however, 
be  provided  under  the  medical  benefit.  With  all  manual  wage-earners 
and  all  other  employed  persons  earning  not  more  than  $100  per  month 
insured,  what  difference  w^ould  such  a  system  have  made  in  view  of  the 
facts  obtained  from  our  investigation  ?  The  answer  to  this  question,  so 
far  as  available  data  permit,  will  be  offered  under  the  following  heads : 

(1)  Organized  health  insurance  as  a  substitute  for  existing  health 
insurance ; 

(2)  Organized  health  insurance  as  a  substitute  for  lowered  stand- 
ards of  living; 

(3)  Organized  health  insurance  as  a  preventive  of  poverty  and 
dependency. 

(1)  Organized  Health  Insurance  as  a  Substitute  for  Existing  Health 
Insurance. 

Under  sickness  costs  it  is  desirable  to  consider  separately  direct 
outlays  and  lost  wages.  In  the  program  of  organized  health  insurance 
assumed,  full  medical  provision  is  made  for  the  first  twenty-six  weeks 
of  sickness  beginning  with  the  first  day,  while  the  sickness  benefit  to 
the  wage-earner  with  its  maximum  period  of  twenty-six  weeks,  does  not 
begin  until  after  a  waiting  period  of  a  week. 

In  order  to  apply  to  wage-earners  and  wage-earning  families  the 
medical  and  sickness  benefits  provided  for  by  the  assumed  organized 
health  insurance  measure,  it  is  necessary  to  determine  the  compensable 
and  noncompensable  periods  for  direct  outlays  and  for  lost  wages. 

« 

(a)  Direct  Outlays  of  Wage-earners  and  Dependent  Members  of  their 
Families. 

The  data  furnished  by  901  wage-earners  reporting  one  or  more 
weeks  lost  from  work  because  of  illness  indicate,  according  to  Table  9,®^ 
that  only  67  lost  more  than  26  weeks.  By  means  of  the  comparison 
made  possible  by  Table  31^*  it  is  found  that  while  901  wage-earners  lost 
a  total  of  6,143  weeks  in  the  first  26  weeks  period,  the  67  wage-earners 
lost  a  total  of  489  weeks  in  the  period  in  excess  of  26  weeks.  On  the 
basis  of  these  figures  the  sum  total  of  weeks  of  lost  work  by  sickness  for 
which  direct  outlays  would  be  provided  for  under  the  medical  benefits 
is  6,143,  while  489  weeks  of  illness  would  not  be  provided  for.  In  per- 
centages this  means  that  the  medical  benefit  would  apply  to  92.6  per  cent 
but  not  to  the  remaining  7.4  per  cent  of  the  time  lost  by  illness.  With 
no  data  at  hand  to  indicate  the  actual  distribution  of  sickness  outlays 
during  the  period  of  illness,  it  seems  conservative  and  not  inapt  to  assume 
their  equal  distribution  throughout  the  entire  time  the  wage-earner  was 

«3  See  p.  208. 
'^  See  p.   301. 


301 


TABLE   31- 


-WAGES   LOST   BY  WAGE-EARNERS   IN  TOTAL  AND   COMPENS- 
ABLE PERIODS  OF  SICKNESS. 


Block 
study. 


Nursing 
service 
study. 


Charity 
study. 


Total  number  of  wage  earners 

Number  losing  time  because  of  sickness 

Number  reporting  time  and  wages  lost 

Total  number  of  weeks  lost 

Number  weeks  lost  minus  one  week 

Number  wage-earners  losing  time  in  excess  of  27  weeks 

Number  of  weeks  lost  in  excess  of  27  weeks 

Total  wage  earnings  of  those  reporting 

Wages  lost  in  26  compensable  weeks 

Lost  wages  of  those  reporting 


4,474 

937 

901 

6,6S2 

5,731 

42 

422 

$676,087 

86,227 

$107,338 


409 

116 

115 

737 

622 

1 

9 

$93,986 

10, 127 

$12,213 


878 

494 

450 

7,824 

7,374 

106 

1,240 

$183, 841 

87,338 

$104,493 


302 

absent  from  work  because  of  illness.  In  the  absence  of  the  tabulation  of 
the  number  of  weeks  of  sickness  of  the  non-gainfully  occupied  members 
of  wage-earning  families,  it  has  been  assumed  that  for  medical  benefit 
the  compensable  period  is  also  92.6^  per  cent  of  the  entire  duration  of  sick- 
ness. As  indicative  of  the  validity  of  this  assumption  is  the  very  close 
averages  of  direct  outlays  for  sickness  of  the  wage-earner  ($35.64)  and  of 
the  non-gainfully  occupied  ($35.87).^^ 

(b)  Lost  Wages. 

The  compensable  period  for  sickness  benefit  in  lieu  of  lost  wages  is 
also  twenty-six  weeks  but  beginning  at  the  end  of  a  waiting  period  of  one 
week.  Table  30  indicates  that  of  the  6,632  weeks  lost  by  wage-earners, 
5,309,  or  80.1  per  cent,  were  compensable,  and  that  1,323,  or  19.9  per 
cent  were  not  compensable.  The  weeks  not  compensable  include  901 
weeks  accounted  for  by  the  one-week  waiting  period  and  422  weeks  in 
excess  of  the  first  twenty-seven  weeks  in  a  year.  We  may  say,  therefore, 
that  roughly  four-fifths  of  the  time  lost  from  work  by  sickness  is  com- 
pensable. But  the  compensation  allowed  by  the  sickness  benefit  is 
partial,  not  full,  and  for  two-thirds  of  the  wages  lost.  So  the  compen- 
sation for  the  total  of  wages  lost,  is,,  under  the  assumed  plan  of  health 
insurance,  53.4  per  cent,  or  slightly  dver  one-half. 

(c)  Compensation  for  Siclcness  Costs. 

Of  the  $107,338  in  wages  lost  by  901  Chicago  wage-earners  last 
year  because  of  disabling  illness,  $86,227  was  lost  in  the  twenty-six 
compensable  weeks  (See  Table  31).  Of  the  $86,227,  only  two-thirds, 
or  $57,484.67,  would  be  covered  by  sickness  benefit. 

Of  the  $24,749  in  direct  outlays  for  sickness  by  1,019  wage-earners, 
92.6  per  cent,  or  $22,918  would  have  been  provided  for  by  the  medical 
benefit. 

One  thousand  six  hundred  and  sixty-seven  wage-earning  families 
giving  complete  sickness  costs  report  $71,733  in  direct  outlays,  hence 
$66,425  would  be  provided  for  under  the  assumed  system  of  organized 
health  insurance.  Of  the  $91,607  in  lost  wages,*^®  assuming  53.4  per 
cent  compensation,  $48,918  would  be  covered  by  the  amount  received 
under  the  assumed  plan.  Of  total  sickness  costs  amounting  to  $163,340 
(of  1,667  wage-earning  families  reporting  in  full),  $115,343  or  70.6  per 
cent,  would  be  met  by  a  system  of  organized  health  insurance.  It  seems, 
therefore,  to  be  conservative  to  state  that  with  other  conditions  un- 
changed seventy  cents  of  every  dollar  of  existing  sickness  loss  to  wage- 
earning  families  would  have  been  met  under  the  system  of  organized 
health  insurance  assumed. 

Assuming  that  the  wage-earning  families  reporting  completely  their 
incomes  and  sickness  costs  are  representative  of  the  whole  group  of  wage- 
earning  families  (2,708)  in  the  blocks  studied,  it  is  possible  to  make 
estimates  of  total  incomes  from  wages,  total  sickness  costs,  and  totaj 
sickness  losses  compensable  under  organized  health  insurance  for  the 
2,708  wage-earning  families. 

^  See   p.    207. 

"•These  families  do  not  include  all  of  the  901  wage-earners  mentioned  above. 


303 

Total  income  from  wages  of  4,295  wage-earners  and  2,708  wage- 
earning  families   estimated   at* $3,524,949 

Total  sickness  costs    (both  direct  outlays  and  lost  wages)    of  2,708 

wage-earning  families  estimated  (understated)  at $192,295 

Total  sickness  cost  percentage  of  total   income  from  wages 5.46  per  cent 

Average    total    sickness    cost    per    wage-earning    family     (somewhat 

understated)      $71.01 

Total   sickness   cost   compensable   under   organized   health   insurance 

estimated  at    $135,760 

Total    compensable   sickness    cost   percentage    of   total    income   from 

wages    4.1  per  cent 

Average  compensable  sickness  cost  per  family t  $50.13 

The  computations  just  made,  while  based  upon  actual  sickness  costs 
during  the  year,  do  not,  and  of  course  could  not,  take  into  account  sev- 
eral minor  factors  that  in  their  sum  total  w^uld,  to  some  extent,  though 
not  considerably,  affect  the  percentage  arrived  at.  Chief  among  these 
disturbing  elements  is  the  effect  upon  eligibility  to  full  benefit  rights 
of  unemployment  during  the  year  due  to  other  causes  than  illness.  For 
the  twelve  months  of  the  study,  however,  there  was  practically  no  unem- 
ployment due  to  lack  of  work. 

(d)   Comparison  Between  Organized  and  Existing  Health  Insurance. 

The  data  in  regard  to  existing  health  insurance  as  obtained  from 
the  block  study^^  make  possible  a  comparison  between  organized  and 
existing  health  insurance. 

For  wage-earners  and  their  families  in  the  block,  nursing  service 
and  charity  groups  the  costs  of  sickness  have  already  been  determined. 
Consideration  here  will  be  limited,  however,  to  wage-earning  families 
in  the  block  study.  A  comparison  of  the  existing  health  insurance  with 
the  assumed  plan  of  organized  health  insurance  will  be  taken  up  under 
the  following  heads :  organization ;  proportion  of  wage-earners  insured ; 
relative  protection  of  insured  persons;  of  wage-earners  with  sickness, 
and  of  wage-earning  families  with  sickness. 

Organization. — A  chief  characteristic  of  existing  health  insurance 
is  its  lack  of  uniformity.  Insurance  against  sickness  risk  is  provided 
in  various  forms  by  several  different  types  of  organizations.  Fraternal 
orders  are  carriers  apparently  for  approximately  one-half  of  the  policies 
providing  disability  insurance  held  by  the  block  families.  Employers 
pay  half  or  all  of  wages  in  a  considerable  proportion  of  cases  where 
benefits  are  received.  Many  workingmen  are  insured  by  commercial 
carriers,  by  establishment  funds  and  by  small  independent  associations 
for  the  most  part  to  be  found  among  immigrant  groups.  Membership 
rights  in  trade  unions  not  infrequently  include  benefits  in  case  of  dis- 
abling sickness.  This  variety  of  types  is  a  natural  result  of  spontaneous 
and  independent  efforts  to  meet  the  risk  of  disability. 

The  assumed  system  of  health  insurance  involves,  of  course,  coor- 
dination of  the  participating  asso(?iations  or  societies  and  the  standard- 
ization of  benefits  and  of  medical  treatment  provided. 

Proportion  of  wage-earners  insured. — The  proportion  of  wage-earn- 
ers insured  under  the  assumed  system  of  organized  health  insurance 
would  probably  range  somewhere  between  90  and  100  per  cent.  All 
wage-earners  except  the  relatively  small  number  not  engaged  in  manual 

*  Estimated  from  Table  4,  pp.   196-97. 

t  These  figures  do  not  include  allowance  for  burial  expenses.  There  were  16 
burials  of  wage-earners  during  the  year.  The  total  outlay  was  $3,428  ;  the  com- 
pensable amount  would  have  been   $1,585. 

^  See  pp.  214-29. 


304 

labor  and  receiving  over  $100  a  month  would  come  under  the  provisions 
of  the  plan.  According  to  the  findings  of  our  block  study  a  much 
smaller  proportion,  or  23.7  per  cent  of  all  wage-earners  and  36.7  per 
cent  of  all  husbands  of  wage-earning  families,  Avere  insured  last  year 
against  risk  of  sickness  or  of  sickness  and  accident. 

These  percentages  do  not,  of  course,  include  that  particular  aspect 
of  life  insurance  that  may  be  considered  sickness  insurance.  The  life 
insurance  benefit  received  at  death  from  "old  line'^  companies  or  from 
fraternal  orders  may  be  as  a  matter  of  fact  regarded  as  providing  for 
three  contingencies — for  expenses  of  last  illness,  for  funeral  expenses, 
and  for  the  surviving  members  of  the  families  during  the  period  of 
readjustment.  How^ever,  as  the  last  sickness  is  but  one  among  many 
illnesses,  provision  for  this  risk  is  only  one  of  minor  significance. 

Relative  protection  provided  insured  persons. — The  protection  of 
health  insurance  includes  both  a  cash  benefit  to  indemnify,  in  part, 
wage  losses  and  a  medical  benefit.  The  assumed  plan  of  health  insur- 
ance, as  already  shown,  would  have  provided  for  53.4  per  cent  of  the 
wage-loss  to  the  group  of  937  wage-earners  sick  and  losing  more  than 
one  week  from  work.  The  disability  policies  or  rights  in  force  last 
year  actually  provided  benefits  of  44.1  per  cent  of  the  wage  loss  to  126 
or  13.4  per  cent  of  the  937  wage-earners  sick  and  losing  more  than  one 
week  from  w'ork.  The  facts  that  while  23.7  per  cent  of  the  wage-earn- 
ers were  found  to  have  disability  insurance  and  that  only  13.4  per  cent 
of  those  sick  received  benefits  cannot  be  entirely  explained  except  by  the 
inadequacy  of  existing  provision.  Under  organized  health  insurance 
100  per  cent  of  the  direct  outlays  for  the  first  26  w^eeks  of  the  illness 
of  the  insured  wage-earner  (as  well  as  of  all  dependent  members  of  his 
family)  would  be  covered.  The  present  carriers  of  disability  insurance 
with  the  exception  of  only  a  few  establishments,  certain  establishment 
funds,  a  few  fraternal  orders  and  independent  societies,  provide  no 
medical  benefit.  An  industrial  policy  in  the  Metropolitan  Life  Insur- 
ance Company  does,  however,  give  to  the  insured  person  the  right  to 
limited  nursing  service  through  an  arrangement  with  the  Visiting 
Nurse  Association. 

With  the  assumed  system  of  health  insurance  in  force  last  year,  the 
average  amount  of  weekly  benefit  for  an  insured  person  when  sick  would 
have  been  $9.61 ;  the  actual  average  weekly  benefit  provided  in  the  health 
policies  was  $6.79.  With  the  assumed  organized  plan  the  weekly  cash 
benefit  would  be  after  a  waiting  period  of  one  week  uniformly  two- 
thirds  of  the  weekly  wages  for  the  duration  of  sickness  not  to  exceed 
twenty-six  weeks  in  any  one  year.  Under  the  existing  situation  the 
maximum  benefit  period  varies  from  five  or  six  weeks  to  a  year  but  is 
most  frequently  thirteen  weeks.  The  cash  benefits  are  in  general  not  a 
proportion  of  wages  (except  where  the  employer  grants  half  or  full 
wages  during  sickness,  or  an  establishment  fund  determines  benefit  by 
a  percentage  of  wages  paid),  but  a  flat  rate  not  closely  related  or  un- 
related to  amount  of  lost  wages.  For  example,  978  out  of  1,055  wage- 
earners  made  insurance  reports  showing  that  while  the  average  benefit 
was  $6.79,  70.3  per  cent  of  the  benefits  provided  w^ere  for  sums  between 


305 

$5  to  $9  a  week  inclusive,  10.9  per  cent  were  for  less  than  $5,  14.1  per 
cent  for  $10  to  $14  inclusive,  and  4.6  per  cent  for  $15  and  over. 

Relative  protection  of  wage-earners  with  sickness. — The  sickness 
losses  of  wage-earners  include  both  lost  wages  and  direct  outlays.  The 
total  wage  loss  last  year  of  937  wage-earners  losing  wages  is  estimated®* 
at  $111,277.  The  amount  of  this  wage  loss  that  would  have  been  in- 
demnified under  the  assumed  system  of  organized  health  insurance  was 
calculated  at  $59,422,  or  53.4  per  cent.  The  estimated  amount^^  actu- 
ally received  by  126  insured  wage-earners  was  $6,607,  or  5.9  per  cent 
of  the  wage  lost. 

The  total  direct  outlays  of  1,100  wage-earners  for  medical  treat- 
ments and  medicines  during  illness  have  been  estimated^*^  at  $26,716. 
Of  this  amount  $24,739,  or  92.6  per  cent,  would  have  been  covered, 
according  to  our  computation,  by  the  medical  benefit  provided  under  the 
assumed  plan  of  organized  health  insurance.  Figures  as  a  basis  for  an 
estimate  of  the  medical  service  now  performed  by  the  existing  carriers 
of  health  insurance  are  not  available.  It  is  not  feasible  to  assign  a  cash 
value  to  the  services  of  the  physician  provided  by  the  establishment 
fund  or  by  the  industrial  enterprise,  or  of  the  nurse  employed  by  an 
arrangement  of  an  industrial  insurance  company  with  the  local  field 
nursing  association.  The  amount,  while  considerable,  would  be,  as 
indicated  by  the  small  number  of  wage-earners  with  these  services,  a 
relativelv  small  fraction  of  the  total  sickness  costs. 

Relative  protection  of  wage-earning  families  with  sichness. — The 
total  sickness  losses  (including  both  wages  and  direct  outlays)  for  1,744 
wage-earning  families  w4th  one  or  more  members  sick  was  estimated  at 
$170,885.'^^  The  amount  of  this  sickness  loss  that  would  have  been 
covered,  according  to  our  calculations,  by  the  application  of  the  assumed 
plan  of  health  insurance  was  $120,645,  or  70.6  per  cent,  as  against 
$7,  601,*^^  or  4.4  per  cent  indemnified  by  existing  health  insurance.  This 
latter  sum  and  per  cent,  while  including  estimated  amount  of  disability 
insurance  received  by  non-gainfully  occupied  members  of  wage-earning 
families,  is  undoubtedly  an  understatement.  As  already  indicated,  a 
medical  benefit  is  now  provided  by  certain  carriers  of  disability  insur- 
ance, the  amount  of  which,  while  known  to  be  not  relatively  large,  can- 
not be  definitely  or  even  approximately  estimated  upon  any  satisfactory 
basis.  The  disadvantageous  situation  of  poor  families  (Class  C)  under 
existing  health  insurance  has  been  repeatedly  indicated  already.''^ 

(2)   As'  a  Preventive  of  Lowered  Standards  of  Living. 

Two  statistical  methods  employed  to  show  lowered  standards  of 
living  among  block  families  were  by  high  sickness  costs  and  by  deficits. 

«» Estimated  on  basis  of  906  reporting  wage-losses  of  $107,595.     See  Table  14. 
p.  219. 

"Estimated  for  126  wage-earners  on  basis  of  125  receiving  $6,555.     See  Table 
14,    p.    219. 

"Estimated  for  1,100    (of  1,222   sick)    on   basis  of   1,019   reporting  completely. 
Sec  Table  7.  p.   206. 

'*  Estimated  on  the  basis  of  1,667  of  these  families  reoorting  $163,340  sickness 
costs. 

"  An   estimate   including   benefits   received   bv  non-gainfully   occupied   members 
of  1,744  wage-earning  families,  estimated  at  $994. 

'^  See  pp.   204,   209,  211,   213,   220,  222,   226.   227.  231.   233.  235,   277,   278,   290. 

—20  H  I 


306 


It  seemed  desirable,  therefore,  to  calculate  the  approximate  elimination 
or  reduction  of  sickness  costs  and  deficits  by  applying  the  standards  of 
the  assumed  system  of  organized  health  insurance. 

Since  the  group  of  343  families  experiencing  a  downward  shift 
in  economic  status  represent,  on  the  average,  higher  costs  of  sickness 
than  the  entire  body  of  wage-earning  families,  it  was  chosen  to  illustrate 
the  effect  of  the  application  of  the  health  insurance  system  assumed. 
The  following  table  shows  by  illness  of  the  members  of  the  families  the 
percentage  of  sickness  costs  that  would  have  been  covered  by  the  cash 
and  the  medical  benefits  received  according  to  the  standards  of  organ- 
ized health  insurance  assumed  for  the  purpose  of  this  study. 


Member  or  members  of  the  family  where 
illness  was  chiefly  responsible 

Total 
cases. 

Percentage  of  total  family  sickness  costs  compensable 

by  an  assumed  system  of  organized 

health  insurance. 

for  sickness  costs. 

1-24 

25-49 

50-59 

60-69 

70-79 

80-89 

90-99 

KG 

Normal  bread  winner  (father  only) 

Mother,  only 

165 
74 
22 
21 
3 
24 

11 

2 

5 

1 

2 

13 

.----. 

13 
3 

1 

25 
2 

1 

54 

7 
7 
1 

38 
2 
6 

22 
2 
2 
2 

2 

1 
2 
1 

11 

58 

Wage-earning  child  or  children 

Unemployed  child  or  children 

2 
17 

Dependent  relative 

3 

Normal  bread  winner  (father)  and  mother 
Normal  bread  winner  (father)  and  wage- 
earning  child  or  children     

1 

2 

2 
5 

1 
1 

1 

7 
3 

1 

13 
1 
1 
3 

1 

Normal  bread  winner  (father)  and  imem- 
ployed  child  or  children 

Normal  bread  winner  (father),  mother  and 
unemployed  child  or  children 

Normal  bread  winner  (father),  mother  and 
wage-earning  child 

Mother  and  wage-earnihg  child  or  children 
Mother  and  unemployed  child  or  children 

1 

1 

1 

12 

Total  number 

343 

100.0 

""o.'o 

18 
5.2 

31 
9.0 

79 
23.0 

58 
16.9 

46 
13.4 

2.0 

104 

Per  cent 

30.3 

This  table  indicates  that,  by  an  application  of  the  standards  of  the 
assumed  system  of  health  insurance,  all  of  the  343  families  would  have 
had  at  'east  twenty-five  per  cent  of  their  sickness  costs  covered  and  that 
approximately  three  tenths  (30.3  per  cent)  of  the  families  Avould  have 
had  their  losses  covered  in  full.  The  cases  where  the  entire  costs  of 
sickness  are  indemnified,  involve,  of  course,  no  wage-loss  and  are,  in 
general,  as  the  table  shows,  those  of  the  non-gainfully  occupied  members 
of  the  family.  In  only  14  out  of  104  families  where  losses  would  have 
been  compensated  in  full  was  the  illness  of  a  wage-earner  partly  or 
wholly  responsible  for  the  sickness  cost. 

This  distribution  of  families  by  percentage  of  sickness  costs  covered 
is  significant.  All  but  slightly  less  than  19  in  20  families  (94.8  per 
cent,  according  to  these  figures,  would  have  had  at  least  half  of  their 
sickness  losses  covered;  somewhat  more  than  17  in  20  families  (85.8 
per  cent)  would  have  had  at  least  three-fifths  of  lost  wages  and  direct 
outlays  compensated. 

A  comparison  of  the  proportion  of  sickness  losses  indemnified  by  the 
particular  member  of  the  family  whose  illness  was  responsible,  shows 
naturally  that  sickness  costs  would  be  covered  in  full  in  relatively  few 
families  where  wage-earners  were  sick.     In  the  165  cases  where  illness  of 


307 


Avage-earniiig  husband  (the  normal  breadwinner)  was  primarily  re- 
sponsible for  sickness  costs,  the  largest  number  (54)  is  grouped  under 
60  to  69  per  cent  of  losses  compensated.  Even  in  this  group,  however, 
it  is  calculated  that  organized  health  insurance  would  have  met  at  least 
half  of  the  costs  of  sickness  in  92.1  per  cent  and  at  least  three-fifths 
in  77.0  per  cent  of  the  cases. 

As  significant  as  the  elimination  and  reduction  of  sickness  costs 
would  be  the  probable  effect  upon  deficits  of  the  application  of  the  stand- 
ard cash  and  medical  benefits  of  the  assumed  system  of  health  insurance. 
The  following  table  shows  the  shift  in  the  range  of  the  amounts  of 
deficits  from  the  actual  situation  last  year  to  the  hypothetical  condition 
under  the  assumed  system  of  organized  health  insurance. 


Deficit  as  affected  by  the  introduction  of  the  assumed 
system  of  organized  health  insurance. 

Per  cent 
of 

Range  of  deficit  in  wage- 
earning  families  dur- 
ing year  of  study. 

Total 
num- 
ber. 

Num- 
ber 
cov- 
ered. 

Number  not  covered  classified  by  varying 
amounts  of  deficit  remaining. 

deficits 

covered 

or  of 

deficit 

Un- 
der 
$50. 

$50 
to 
99. 

$100 

to 

149. 

$150 

to 

199. 

$200 

to 

299. 

$300 

to 

399. 

$400 

to 

499. 

$500 
and 
over. 

remain- 
ing under 
$50. 

Under  $50 

65 
50 
34 

9 
32 
14 

4 
14 

56 

29 

11 

6 

11 

2 

1 

1 

9 

16 

5 

6 

1 

100.0 

$50-$99 

5 

13 

1 

5 

1 
1 

90.0 

$100-$149 

5 
1 

1 
1 

47.1 

$150-$199 

1 
5 
2 

66.7 

$200-$299 

4 
6 

53.1 

$300-$}99 

1 

2 

21.4 

$400-$199 

'      25  0 

$500  and  over 

2 

4 

7 

7  1 

Total 

222 

117 
52.7 

37 
16.7 

26 

11.7 

8 
3.6 

8 
3.6 

12 
5.4 

3 
1.4 

4 
1.8 

7 
3.1 

69.4 

Per  cent 

Certain  significant  facts  are  shown  in  this  table. 

1.  Over  half  the  deficits  (52.7  per  cent)  would  have  been  covered 
had  the  assumed  standards  of  organized  health  insurance  been  in  force 
during  the  year  of  the  study. 

2.  Practically  7  out  of  every  10  deficits  (69.4  per  cent  would  either 
have  been  eliminated  (52.7  per  cent)  or  reduced  to  an  amount  under 
$50  (16.7  per  cent)  carried,  in  most  cases,  without  great  economic  in- 
convenience by  the  family. 

3.  The  proportion  of  deficits  entirely  covered  or  reduced  below  $50 
by  indemnification  of  sickness  costs  under  the  assumed  system  of  health 
insurance  naturally  varies  with  the  amount  of  actual  deficit  during  the 
year  as  follows:  under  $50,  100  per  cent;  $50-$99,  90  per  cent;  $100- 
$149,  47.1  per  cent;  $150-$199,  66.7  per  cent;  $200-$299,  53.1  per  cent; 
$300-$399,  21.4  per  cent;  $400-$499,  25  per  cent,  $500  and  over,  7.1  per 
cent.  In  analyzing  these  figures  it  should  be  kept  in  mind,  as  already 
shown/*  that  all  of  the  deficit  incurred  is  not  necessarily  because  of 
sickness  costs.    - 

The  calculation  of  deficits  as  worked  out  in  the  above  table  prac- 
tically took  for  granted  that  the  additional  outlay  for  premiums  from 

"•*  See  pp.  290-91. 


308 

wage-earning  families  to  carry  the  costs  of  the  assumed  system  of  organ- 
ized health  insurance  would  have  had  no  effect  upon  deficits.  This 
assumption  is  probably  correct  for  the  great  majority  of  wage-earning 
families.  An  added  but  foreseen  outlay,  especially  if  distributed 
throughout  the  year,  can  be  met  by  a  readjustment  of  expenditures 
without  necessarily  creating  a  deficit.  The  purchase  of  Liberty  Bonds 
by  wage-earning  families  who  previously  had  succeeded  only  in  making 
ends  meet  did  not  create  many  family  deficits.  It  is  the  added  but  un- 
forseen  outlay,  such  as  that  of  sickness  costs,  which  results  in  the  sum  of 
outlays  in  excess  of  family  income. 

Nevertheless,  the  cost  of  administering  an  assumed  system  of  organ- 
ized health  insurance  cannot  be  ignored,  and  the  effect  of  its  introduction 
upon  deficits,  if  other  expenditures  had  remained  the  same  is  a  matter 
of  interest  though  not  of  decisive  importance.  It  will  be  recalled  that  last 
yearns  sickness  costs  compensable  under  the  assumed  plan  were  calculated 
at  4.1  per  cent  of  the  total  wage  income  of  the  entire  group  of  2,708 
wage-earning  families  in  the  blocks  studied.  Despite  economies  possi- 
ble under  unified  organization  and  the  possible  though  uncertain  re- 
duction of  the  duration  of  sickness  because  of  the  more  adequate  treat- 
ment provided,  the  per  cent  of  cost  to  wage  income  would  probably 
have  been  closer  to  5.0  than  to  4.0  per  cent  of  wages.  This  increase 
would  result  from  the  additional  expenditure  required  to  carry  existing 
free  medical  service,  from  the  provision  of  medical  facilities  and  treat- 
ment more  adequate  than  those  existing,  and  from  the  probable  in- 
crease in  the  average  number  of  weeks  lost  from  work  because  of  the 
right  to  cash  benefit  during  disabling  illness.  Assuming  that  2.5  per 
cent  (half  of  the  cost)  was  charged  against  the  wage-earner  and  the 
other  half  charged  to  industry,  a  calculation  was  made  of  the  effect  of 
this  added  outlay  in  connection  with  benefits  provided  under  the  assumed 
plan  upon  the  deficits  of  the  222  families  without  any  other  change  in 
expenditures.  It  was  found  that  of  the  222  families  with  deficits,  the 
deficit  would  have  been  covered  in  96  or  43.2  per  cent  of  the  cases  (as 
compared  with  52.7  per  cent  where  no  additional  outlay  for  cost  of  the 
system  was  assumed).  The  deficits  with  allowance  for  the  cost  of  the 
premiums  would  have  been  under  $50  in  the  case  of  33  families  or  14.9 
per  cent  of  the  total  number  (16.7  without  premium)  ;  $50  but  less  than 
$100  in  32,  or  14.4  per  cent  (11.7  per  cent  without  premium)  ;  $100  but 
less  than  $150  in  11.4  per  cent  (3.6  per  cent  without  premium)  ;  $150 
but  less  than  $200  in  2  or  0.9  per  cent  (3.6  per  cent  without  premium) ; 
$200  but  less  than  $300  in  17,  or  7.6  per  cent  (5.4  per  cent  without 
premium)  ;  $300  but  less  than  $400  in  5,  or  2.2  per  cent  (1.4  per  cent 
without  permium)  ;  $400  but  less  than  $500  in  2,  or  0.9  per  cent  (1.8 
per  cent  without  premium)  ;  $500  and  over  in  10  or  4.5  per  cent  (3.1 
per  cent  without  premium). 

These  calculations  of  the  effects  of  the  hypothetical  application  of 
the  assumed  standards  of  organized  health  insurance  to  the  actual 
economic  experience  of  wage-earning  families  have,  of  course,  obvious 
limitations.  The  figures  as  given  for  sickness  costs  and  deficits  repre- 
sent the  theoretical  expectation,  based  upon  sickness  losses  under  exist- 


309 

iug  conditions,   of  the   situation   under  the   assumed  plan  and  must, 
accordingly,  be  taken  only  as  presumptive  and  indicative. 

(3)  As  a  Preventive  of  Poverty  and  Dependency. 

So  far  as  poverty  is  considered  as  a  relative  matter,  as  a  reduction 
in  income  or  as  an  unusual  and  unprovided  for  outlay  sufficient  to  require 
a  radical  adjustment  in  habits  of  expenditure,  its  condition  as  a  result 
of  sickness  and  as  affected  by  the  substitution  of  an  assumed  organized 
system  for  existing  health  insurance  has  just  been  considered  under  the 
discussion  of  the  prevention  of  lowered  standards  of  living.  But  poverty 
may  also^^  be  defined  more  objectively  as  existence  below  a  minimum 
subsistence  standard  of  living.  The  families  in  our  block  study  in  Class 
C  are  those  whose  incomes  are  insufficient  to  meet  the  requirements  of  a 
conservatively  estimated  charity  budget.^^  The  number  of  families  in 
Class  C  according  to  normal  economic  status  (actual  income  plus  wages 
lost  because  of  sickness)  was  280.  If  the  actual  economic  status  (actual 
income  minus  direct  outlays  due  to  illness)  of  the  families  be  taken  the 
number  of  families  in  Class  C  is  increased  to  375.  This  additional  num- 
ber of  families,  95,  represents  those  in  Classes  W,  A  and  B  who  Avere  de- 
pressed into  poverty  because  of  lost  wages  and  direct  outlays  due  to  sick- 
ness. The  application  of  the  assumed  standards  of  cash  and  medical 
benefits  to  each  of  these  95  cases  in  turn  indicates  that  only  16  or  16.8 
per  cent  would  have  been  submerged  below  the  minimum  requirements 
of  subsistence  had  organized  health  insurance  been  in  force  during  the 
year.  When  combined  with  the  data  relating  to  the  causes  of  poverty, 
this  means  that  somewhat  more  than  one-fifth  of  the  poverty  in  the 
block  wage-earning  families  would  have  been  eliminated  had  the  assumed 
system  of  health  insurance  been  in  force.  On  the  other  hand,  the 
premium  charged  (2i/2  per  cent  of  wages)  would  have  depressed  6  or  1.0 
per  cent  of  the  B  families  below  the  poverty  line.  The  figure  (6) 
and  the  figure  (79)  given  above  for  families  that  would  have  been  kept 
above  the  poverty  level  show  the  net  effect  the  system  assumed  would  have 
had  upon  the  number  of  these  families  in  the  poverty  (Class  C)  group. 

The  consideration  of  the  effect  of  the  application  of  the  assumed 
system  of  health  insurance  upon  the  reduction  or  elimination  of  de- 
pendency falls  under  two  heads — medical  charity  and  general  charity 
defined  as  material  relief. 

Application  for  free  medical  service,  no  matter  how  disguised,  is, 
in  fact,  an  appeal  to  charity.  Of  2,005  wage-earning  families  with  sick- 
ness in  the  blocks  studied,  13.6  per  cent  had  free  service  of  physician, 
6.1  per  cent  free  nursing  service,  10.0  per  cent  free  hospital  care,  and 
11.3  per  cent  free  dispensary  treatment."^^  At  least  one  member  of  588 
families,  or  29.3  per  cent  of  the  2,005  families  with  one  or  more  cases 
of  sickness,  secured  some  form  of  free  medical  service  during  the  year. 
Moreover,  there  were  a  considerable  number  of  other  cases  where  the 
fees  paid  for  the  nursing  or  the  dispensary  service  would  cover  only  a 
part  of  the  cost  of  providing  it.     These  are  semi-charity  cases. 

"Page    286. 

T«  For  a  fuller  explanation,  see  pp.  185-88. 

"fifee  p.  243. 


310 


* 


This  large  proportion  (nearly  three  of  ten  families  with  sickness) 
which  were  found  to  have  secured  free  medical  treatment  represents 
need  rather  than  abuse.  At  any  rate  the  dispensary  study  showed  that 
less  than  one  family  in  twenty  was  financially  able  to  have  paid  for  the 
kind  of  service  obtained.'^^  The  assumed  system  of  health  insurance 
would  provide  for  the  insured  wage-earner  and  for  the  dependent  mem- 
bers of  his  family  all  necessary  medical  benefits  not  to  exceed  twenty- 
six  weeks  of  disability  in  any  consecutive  twelve  months. 

We  come  finally  to  the  question,  how  far  Avould  the  assumed  system 
of  health  insurance  have  reduced  the  number  who  were  granted  material 
relief?  Or,  in  different  words,  to  what  extent  would  the  assumed 
system  have  prevented  dependency? 

The  data  obtained  from  the  investigation  of  families  included  in 
the  Block  Study  may  be  brought  to  bear  upon  this  question.  Of  2,708 
wage-earning  families  studied,  50  were  found  to  have  received  material 
relief  during  the  year.  In  6  of  these  50  cases  there  had  been  no  sick- 
ness; the  dependency  was  the  result  of  other  causes.  It  was  found, 
moreover,  that  while  sickness  entered  into  14  other  cases,  it  was  of 
minor  importance;  the  other  factors  present  would  have  reduced  the 
families  to  dependency  anywa}',  and  the  only  ameliorative  effect  of 
health  insurance  would  have  been  to  reduce  but  slightly  the  extent  to 
which  they  relied  upon  material  relief. 

It  was  found,  in  the  third  place,  that  disability  due  to  chronic 
disease  of  the  normal  breadwinner  was  the  cause  of  dependency  in  16 
cases.  In  9  of  these  16  cases  the  normal  breadwinner  had  not  been  able 
to  work  at  all  during  the  year,  and  usually  for  a  longer  period  of  time. 
Unless  it  carried  with  it  invalidity  benefits  considerably  in  excess  of 
twenty-six  weeks,  health  insurance  would  have  made  little  or  no  differ- 
ence in  these  cases.  As  against  these,  there  w^ere  2  cases  in  which  the 
normal  breadwinner,  though  suft'ering  from  chronic  illness,  continued  in 
employment  with  such  regularity  that  he  would  not  have  been  entitled 
to  a  cash  benefit  in  partial  compensation  of  his  regular  earnings,  which 
were  no  doubt  reduced  by  impaired  efficiency.  Finally,  there  were  5 
cases  in  which  the  normal  breadwinner  was  employed  a  part  of  the  time 
and  would  have  been  entitled  to  a  cash  benefit  when  disabled.  How  far 
his  losses  would  have  compensated  it  is  impossible  to  estimate,  because 
the  irregularity  of  his  employment  leaves  doubt  as  to  the  extent  of  his 
insurance  rights.  It  is  evident,  therefore,  that  the  assumed  system  of 
health  insurance  would  have  prevented  little  of  the  dependency  due  to 
chronic  illness,  unless  the  medical  care  provided  under  it  proved  effective 
in  preventing  the  illness  or  in  reducing  its  seriousness: 

In  the  fourth  place,  and  finally,  there  were  14  cases  in  which 
dependency  was  due  to  the  acute  illness  of  the  normal  breadwinner  or 
other  member  of  his  family.  In  4  cases  the  assumed  system  of  health 
insurance  with  its  cash  and  medical  benefits  (and  premium  of  2.5  per 
cent  charged  against  wages)  would  have  been  insufficient  to  cover  the 
material  relief  granted  by  charitable  agencies,  unless  the  system  was 
effective  in  reducing  the  seriousness  of  the  disability.     There  remain, 

"Special  Report  III. 


311 

then,  only  10  cases  where  dependenc}^  would  have  been  prevented,  had 
the  assumed  plan  been  in  force. 

In  the  light  of  this  examination  into  each  case  of  dependency  among 
the  wage-earning  families  in  the  blocks,  we  may  briefly  analyze  the  data 
gathered  in  our  charity  study  and  in  the  survey  of  the  experience  of 
Chicago  charitable  agencies. 

Of  the  628  families  investigated  in  the  charity  study,^^  physical 
disability  other  than  that  resulting  from  industrial  accident  was  assigned 
as  the  cause  of  dependency  in  409  or  65.1  per  cent  of  the  cases.  Among 
these  409  cases  there  were  307  where  the  chronic  disability  of  the  normal 
wage-earner  was  ascribed  as  the  chief  cause  of  dependency.  In  76  of 
the  307  families  where  the  normal  breadwinner  had  been  unable  to  work 
at  all  during  the  year,  and,  in  many  cases,  for  a  much  longer  period, 
little  or  no  benefit  under  the  assumed  system  of  organized  health  in- 
surance could  have  been  expected.  In  106  additional  cases  where  the 
period  lost  from  work  was  in  excess  of  the  twenty-seventh  or  final  com- 
pensable week  in  the  year,  a  considerable  part  of  the  sickness  cost,  assum- 
ing eligibility  to  benefit,  would  have  been  entirely  unindemnified.  How- 
ever, in  these  106  cases,  as  well  as  in  the  remaining  125  cases  where  the 
time  lost  from  work  was  less  than  twenty-seven  weeks,  the  question  of 
eligibility  to  full  benefit  rights  is  crucial.  Many  of  them  are  of  the 
casual  labor  type  and  a  large  percentage  of  them  would  doubtless  fail  to 
maintain  full  benefit  rights.  At  any  rate,  without  the  inclusion  of  an 
invalidity  cash  benefit  extending  over  a  much  longer  period  than  26 
weeks,  health  insurance  would  merely  postpone  and  not  prevent  the 
appeal  to  charity  in  practically  all  cases  of  chronic  disease.  There 
remains,  finally,  the  group  of  102  families  where  acute  illness  or  injury 
from  non-industrial  accident  of  the  normal  breadwinner  was  the  cause 
of  dependency.  As  already  seen  in  the  study  of  dependency  in  the  block 
families,  the  appeal  to  charity  in  not  all,  but  in  the  greater  number  of 
these  would  probably  have  been  prevented. 

The  experience  of  the  United  Charities  for  eight  years  may  be  con- 
sidered in  this  connection.  In  from  one-half  to  two-thirds  (according 
to  the  year  considered)  of  the  problems  involved  in  dependency,  sick- 
ness as  a  condition,  does  not  enter.  The  average  of  the  proportion  of 
dependency  charged  to  physical  disability  (excluding  industrial  accident), 
for  the  eight  year  period  is  36.7  per  cent,^*^  or •  approximately  three- 
eights.  During  these  eight  years  the  ratio  of  chronic  to  acute  cases  was 
46.7  to  53.3.^^  If  the  conclusions  arrived  at  above  may  be  applied  here, 
it  is  doubtful  whether  the  assumed  system  of  health  insurance  would 
have  proved  to  be  a  complete  substitute  for  charity  in  as  many  as  one-half 
of  the  cases  where  material  relief  had  been  granted  because  of  disabling 
sickness.  We  may,  accordingly,  expect  a  reduction  of  not  to  exceed 
one-half  in  dependency  caused  by  disability  and  of  not  to  exceed  three- 

"The  statistics  in  this  paragraph  are  based  upon  data  presented  in  Table  28, 
p.   269. 

«>For  the  eight  year  period,  the  average  proportion  for  physical  and  mental 
disability  was  40.2  per  cent,  from  which  3.5  per  cent  is  subtracted  for  mental 
disability  and  industrial  accident.     See  Table  26,  p.   259. 

"  See  Table  27,  p.  264. 


312 

sixteenths  in  all  dependency.     Indeed,  the  actual  outcome  might  fall  con- 
siderably short  of  this  estimate. 

The  findings  in  this  section  may  now  be  summarized. 

(1)  The  effect  of  the  introduction  of  a  system  of  organized  health 
insurance  would  have  had  its  most  marked  result  in  affecting  the  dis- 
tribution of  the  burden  of  sickness  losses,  in  covering  sickness  costs 
and  in  eliminating  or  reducing  deficits: 

(a)  Approximately  70  per  cent  (as  compared  with  about  6  per  cent 
under  existing  health  insurance)  of  last  year's  sickness  costs  in  the  block 
wage-earning  families  would  have  been  covered  at  a  cost,  when  distributed 
among  all  wage-earning  families,  of  4.1  per  cent  of  wages  received  plus 
such  allowance  as  would  be  required  for  administration,  enhancement 
of  costs,  etc. 

(b)  Of  the  343  families  experiencing  downward  shifts  in  economic 
status,  30  per  cent  would  have  had  sickness  costs  completely  covered,  and 
approximately  85  per  cent  would  have  had  them  either  covered  or  con- 
siderably reduced  (60  per  cent  and  over). 

(c)  Deficits  would  have  been  eliminated  in  52.7  per  cent  of  the 
families  with  sickness  failing  to  make  ends  meet  (43.2  per  cent  if 
allowance  were  made  for  premium  of  2.5  per  cent  charged  against  wages 
to  cover  the  cost  of  the  assumed  system) ;  deficits  would  have  been  elimin- 
ated or  reduced  to  amounts  under  $50  in  69.4  per  cent  of  these  families 
(58.1  per  cent  with  allowance  for  premium). 

(2)  The  assumed  system  of  health  insurance  would  have  prevented' 
a  considerable  proportion  of  poverty  and  dependency  caused  by  sickness, 
but  a  relatively  small  percentage  of  all  poverty  and  dependency: 

(a)  The  reduction  in  poverty  caused  by  the  year's  sickness  would 
have  been  about  three-fourths,  in  all  poverty  about  one-fifth. 

(b)  The  highest  reduction  to  be  expected  in  the  cases  of  dependency 
caused  by  sickness  is  one-half,  and  in  all  cases  of  dependency  three- 
sixteenths. 

The  findings  of  this  section  are  not  presented  as  absolutely  con- 
clusive and  final.  They  must  be  weighed  in  the  light  of  the  necessary 
limitations  of  the  hypothetical  application  of  assumed  standards  to  an 
actual  situation  considered  as  unaffected  by  their  introduction.  Again, 
the  evidence  presented  is  largely  circumstantial  and  presumptive,  and 
should  be  accepted  with  due  reservation  for  this  fact.  Moreover,  in 
several  instances  the  numbers  upon  which  the  findings  have  been  based 
are  small.  While  larger  numbers  probably  would  not  materially  affect 
the  result  (attested  by  the  coherent  testimony  of  the  separate  studies  of 
block,  nursing  service,  and  charity  families),  they  would  have  strength- 
ened the  conclusions.  While  the  data,  then,  cannot  be  regarded  as 
sufficient  to  establish  beyond  question  the  findings  arrived  at  above, 
they  have  been  presented  in  some  detail  because  they  are  suggestive, 
indicative  and  probable  upon  points  of  interest  to  the  Commission  and 
the  public. 


313 


APPENDIX     A.       FAMILY     SCHEDULE. 


On   list   of. 


Schedule  number 


Investigator 
Date    


HEALTH    INSURANCE  COMMISSION. 
Family  Schedule,  F.  2. 


Nationality  of  family- 


Name, 


Address. 


House  or  apartment.    Front  or  rear.    Floor.    Number  of  rooms.    Number  of  persons. 


Condition  of  house  :  Good — fair — bad  ;  Clean — dirty — filthy.         Rent  per  month. 


4.  Family  Status  and  Employment. 


Members  of 

Sex. 

Age. 

■ 

Present  or  usual 
employment. 

Average 

earnings 

per 

week. 

Weeks  unemployed 

last  12  months 

because  of 

Earn- 
ings 
last  12 
months. 

Number 
of  em- 
ployers 

family. 

Sickness. 

Other 
reason. 

during 

last  12 

months. 

Father 

Mother 

Children: 
1. 

2 

t    , 

5. 

6 

5.  Other   sources   of   income    (specify) 


6.  Total  family  income  last  year? Surplus   or   deficit?. 


7.  How  was  deficit  met?    (enter  relief  in  full) 


8.  Value   of  property   owned Encumbrance   on   same, 


9.  Other  indebtedness 


314 


10.   Sickness  during  last  12  months. 


Members  of 
family. 

Nature  of  illness. 

Dura- 
tion. 

Doctor  em- 
ployed (Co. 
or  other). 

Doctor 
bill. 

Hospital  care 
(name). 

Hospital 
bill. 

Nursing  care 

— by  whom 

and  cost. 

Father 

Mother . . 

Children: 
1 

2 

3 

4 

5 

• 

6 

11.  Dispensary  record  during  last  twelve  months. 


Names  of  dispensaries 

visited  with  number 

of  visits  to  each. 

Nature  of 
ailment. 

Nature  of 
treatment. 

Dispensary  charges. 

Members  of 
family. 

Admis- 
sion fee. 

Charge  for  medicines  or 
operation  (specify). 

Father 

! 

Mother 

Children: 

1 

2 

3 

, 

.     • 

4 

5 

6 

12. 


Doctor's  fee  for  house  visit.     Office  visit.     Cost  of  medicine  for  the  year. 


13.  How  is  dental  work  secured? Cost  of  dental  work  for  the  year?. 


14.  Note  any  neglect  of  dental  work, 


315 

15.  Insurance. 


Life  insurance. 

Sickness  insurance  or  sick  fund. 

Members  of 
family. 

Amount 
carried. 

Name  of  com- 
pany. 

Type  of  company 
— industrial,  fra- 
ternal order, 
union,  etc. 

Weekly 
premium. 

Name 

of  carrier  or 

fund. 

Weekly 
premium. 

Weekly 
benefit. 

Father 

Mother 

Children: 
1 

2 

3.     . 

4 

5. 

16.  Note  lapses  of  insurance  policies  with  reason, 


17.  For   each   member    of    family   who    received    insurance    during   the    last    twelve 
months,   specify  amount  received  and  state  what  was   done  with  life  or  in- 


dustrial insurance  policies  paid. 


18.  What,  if  any,  provision  is  made  by  any  of  the  above  institutions   (in  "15")   for 


medical  or  nursing  care?. 


19.  Has  any  death  occurred  in  family  in  past  year? If  so,  cost  of  burial?. 


20.  Has  a  child  been  born  in  family  during  past  year? Physician 


or  midwife  employed?. , Fee  of  same. 


Nursing  care  and  fee. 


Hospital  service. 


Hospital  bill. 


If  employed,  number  of  weeks  absent  from  work  before  confinement?. 


If  employment  resumed,  number  of  weeks  after  confinement?. 


21.  Note  here  any  significant  facts  not  entered  above,  such  as:  (a)  illness  of  long 
standing  and  doctors  employed  and  bills;  (b)  connection  of  doctors  with 
dispensary;  (c)  quack  doctors  and  patent  medicines;  (d)  delay  in  securing 
treatment  with  reason;  (e)  attitude  towards  dispensary;  (f)  changes  in 
standard  of  living  due  to  sickness  (moving  to  cheaper  quarters,  wife  or 
children  taking  employment,  etc.)  ;  (g)  charity  record,  including  date  of 
first  application  and  any  information  bearing  on  the  cause  of  the  situation, 
the  income  per'  month  while  helped  by  charity  during  present  emergency, 
etc.     All   of  these   points   may   possibly  be   combined   into   a   story. 


316 

APPENDIX   B.      INSTRUCTIONS   FOR   INVESTIGATORS. 
General. 

The  General  Assembly  of  Illinois  by  Act  approved  June  23,  1917,  created  a 
special  Health  Insurance  Commission.  It  is  collecting  data  for  its  report.  Data 
collected  are  for  scientific  use  only ;  all  information  must  be  regarded  as  confi- 
dential. In  all  cases  these  things  should  be  explained  and  persons  interviewed 
should  be  told  that  the  facts  given  by  them  will  not  be  used  except  in  making  up 
general  tables.  It  should  be  made  clear,  also,  that  this  is  a  government  investi- 
gation. Each  agent  collecting  data  will  have  proper  credentials,  countersigned  by 
the  Governor  of  the  State.  Agents  should  secure  accurate  information  bearing 
upon  such  points  as  find  place  in  this  schedule.  Be  careful  to  set  down  everything 
you  learn  of  any  importance  for  the  purpose  of  the  investigation.  Pertinent  infor- 
mation not  fitting  into  any  special  place  should  be  entered  at  the  end  of  the 
schedule. 

Those  collecting  data  for  the  commission  should  seek  to  develop  the  cooperative 
spirit  on  the  part  of  those  interviewed.  Unless  this  is  developed  good  data  can- 
not be  secured.  Thought,  patience,  tact,  and  courteous  treatment  are  indispensable. 
Investigators  must  not  demand  anything ;  they  should  be  able  to  command  every- 
thing because  of  the  tremendous  importance  of  the  data  to   everybody. 

Every  question  mwst  have  an  answer.  Where  information  cannot  be  ob- 
tained, write  in  "n.r."  for  no  report.  Where  the  question  is  not  in  point,  either 
because  of  the  answer  to  a  previous  question  or  for  other  reasons,  draw  a  dash  in 
the  space  for  the  answer. 

Write  so  that  entries  can  be  read. 

Detailed  Instructions. 

"On  list  of"  means  United  Charities,  Central  Free  Dispensary,  Block  4700 
South  Halsted,  etc.  Schedules  of  each  investigator  are  to  be  numbered  consecu- 
tively,  beginning  with   1. 

1.  Nationality.  If  white  and  native  born,  enter  "U.  S.  White ;"  if  colored, 
enter  "Negro;"  if  foreign  born  enter,  as  a  rule,  country  of  birth  (e.  g.  Italy)  but  in 
case  of  Austria  and  Russia  indicate  race  by  entering  "Russian  Jew,"  "Galician 
Pole  etc,"     Country  of  birth  or  race  of  father  determines  entry. 

2.  Enter  H.  or  A.  A  house  is  a  one  family  dwelling.  The  two  following 
entries  are  not  to  be  filled  out  for  house : 

F.  or  R.  (Front  or  rear).  This  refers  to  location  of  apartment  in  the  house. 
If  a  middle  or  through  apartment  is  found  write  that  in.  If  apartment  is  in  a 
rear  house,  that  may  be  indicated  by  giving  first  location  in  the  house  and  adding 
"R.   H."     Enter  B   or  floor  number.     Enter  number  of  persons   including  lodgers. 

3.  Enter  G,  F  or  B  and  C,  D  or  F. 

4.  Enter  only  children  living  at  home  and  children  who  have  died  within  the 
last  12  months.  Names  of  children  should  be  entered  and  in  order  of  birth.  If 
father,  mother  or  child  is  dead,  enter  that  fact  with  date  of  death  in  space  im- 
mediately following  name.  Present  employment,  earnings  per  week,  lost  time,  and 
yearly  earnings  can  be  worked  together.  Average  earnings  per  week  means  at 
present  or  when  on  last  job.  In  general,  the  weekly  and  yearly  earnings  should 
check  when  proper  allowance  is  made  for  unemployment.  One  exception  to  this 
is  when  the  rate  of  pay  has  changed  during  the  year ;  another  when  women  and 
children  have  started  to  work  during  the  year.  Either  fact  should  be  explained 
in  note. 

If  unemployed  write  in  "unemployed"  and  give  usual  employment.  If  present 
employment  differs  from  usual,   give  both. 

Give  specific  nature  of  job  and  industry,  e.  g.  Laborer-Stock  Yards.  If  man 
changes  employers  frequently  enter  "Casual"  e.  g.  Labor-casual.  Enter  "o.  a." 
if  in  business  for  self,  e.  g.  "Grocer-o.  a." 

Weeks  unemployed  is  to  be  filled  in  for  wage-earners  only.  Weeks  unem- 
ployed because  of  sickness  refers  to  sickness  of  wage-earner  only.  Unemployment 
because  of  sickness  of  others  should  be  entered  under  "other  reasons."  "Other 
reasons" — do  not  specify  reason.  Give  total  weeks  unemployed.  Notice  this  does 
not  include  single  days  unemployment. 

Members  of  the  family  who  did  not  start  work  until  some  time  within  the 
year  are  not  to  be  counted  unemployed  for  the  time  when  that  was  their  normal 
condition.  If  they  work  because  of  sickness  of  wage-earner,  be  sure  to  note  that 
fact  under  "21." 

Number  of  employers  during  year-not  jobs.     Names  of  employers  not  wanted. 

5.  Enter  amount  from  each  source.  Probable  sources  are  boarders  or  lodgers, 
rent  from  property,  insurance  policies,  sick  benefits.     Do  not  include  relief  or  gifts. 

6.  Total  family  income  will  normally  equal  sum  of  earnings  in  4  plus  5.  When 
there  are  children  of  legal  age  whose  earnings  are  not  contributed  to  family  in- 
come, put  their  contributions  under  5  and  explain  in  note  why  6  does  not  equal 
4  plus   5. 

Surplus  or  deficit — give  amount.  Where  deficit  is  made  up  by  relief  in  kind, 
estimate  value  if  possible  ;  otherwise  itemize  things  actually  received. 

7.  Specify  amount  from  each  source  ;  get  relief  from  U.  C.  from  their  records. 
Notice  that  other  indebtedness  (9)  is  repeated  here  unless  incurred  previous  to 
last  year. 

8.  Enter  only  value  of  real  property  owned. 

9.  Bills  overdue  but  not  current  bills  are  to  be  entered.  Specify  nature  and 
amount  of  each  debt,  e.  g.  "grocer,  $20." 

10.  Make  some  entry  for  every  member  of  family  in  order  used  in  4.  Names 
need  not  be  re-entered.  Answer  every  question  for  every  sickness.  If  one  member 
of  the  family  has  had  more  than  one  sickness,  use  two  lines  and  change  number- 
ing at  sides.     As  to  what  constitutes  sickness,   the  investigator  must  use   his  best 


317 

judgment.  Do  not  enter  minor  chronic  complaints  such  as  ordinary  rheumatism, 
indigestion,  etc.,  which  do  not  incapacitate  patient  for  usual  work.  Serious  com- 
plaints such  as  tuberculosis  should  of  course  be  entered  even  though  patient  is 
still  at  work.  In  other  cases,  do  not  count  a  wage-earner  ill  unless  he  is  in- 
capacitated for  work  for  a  week  or  more  and  do  not  count  others  ill  unless  they 
are  confined  to  bed  for  that  same  time.  Exceptions  to  this  rule  should  of  course 
be  made  in  any  case  of  any  important  shorter  illness,  as  e.  g.  removal  .of  tonsils. 
Maternity  cases,  including  abortions,  etc.,  are  not  to  be  included  here  but  listed 
under  20. 

Duration.  Usually  time  lost  or  confined  to  bed.  Express  in  weeks.  Cases 
in  which  patient  is  partially  incapacitated  present  more  difficulties  ;  duration  may 
be  counted  from  time  patient  stopped  his  usual  for  lighter  work,  from  time  of 
diagnosis  if  there  is  reason  to  think  it  was  diagnosed  reasonably  early,  or  from 
time  when  patient  first  complained.  If  duration  is  over  a  year,  express  in  years 
and  months. 

Doctor.  Specify  county  or  other.     Do  not  enter  name  of  doctor. 

11.  Make  entry  for  every  member  of  family  as  in  10.  Enter  visits  for  ex- 
amination as  well  as  for  treatment.  Nature  of  treatment.  Be  as  specific  as 
possible. 

12.  This  means  fee  for  each  visit. 

15.  Make  entry  for  each  member  of  family  under  both  life  and  sickness  in- 
surance. Include  insurance  at  present  carried  and  insurance  carried  at  time  of 
death  for  members  of  the  family  who  have  died  in  the  past  12  months.  Care 
should   be   taken  to   get   accurate   information   on   these,  questions. 

Amount.  If  children's  insurance  varies  with  age  and  length  of  time  policy  is 
held,  give  minimum  and  maximum. 

Name  of  Company.  If  there  is  not  space  to  write  out  name,  abbreviate  and 
explain  abbreviation  in  foot-note  except  for  well-known  companies,  e.  g.  "Pru- 
dential,"  "Metropolitan." 

Under  sickness  insurance,  weekly  benefit  means  the  benefit  called  for  by  the 
policy  not  the  benefit  actually  received.  Enter  the  amount  of  cash  benefit  and 
add  "And  medical  attention"  or  whatever  is  necessary  to  indicate  the  rights  of 
the  insured.  If  more  space  is  needed  write  "note"  and  describe  fully  at  end  of 
schedule  or  bottom  of  page. 

20.  Include  still  births,  miscarriages  and  abortions.  Enter  "P"  or  "M."  If 
nursing  care  given  by  association,  e.  g.  "VNA" — specify.     Enter  name  of  hospital. 


318 


SPECIAL  REPORT  II.  A  STUDY  OF  THE  DISABILITY  DATA 
OF  A  SELECTED  GROUP  OF  ASSOCIATIONS  IN  THE 
UNITED  STATES. 

(H.  W.  Kulm,  Ph.  D.) 


[Note  hy  the  Secretary. — This  special  report  sets  out  dates  collected  relating 
to  th«  morbidity  experience  of  establishment  funds  and  other  mutual  organizations. 
The  statistics  contained  in  Part  I  were  gathered  by  the  Health  Insurance  Commis- 
sions of  Ohio,  Connecticut,  Pennsylvania  and  Illinois.  The  statistics  in  Part  II  are 
for  the  Workmen's  Sick  and  Death  Benefit  Fund  of  New  York.  Through  the  cour- 
tesy of  Commissioner  Royal  Meeker  of  the  United  States  Bureau  of  Labor  Statistics, 
these  data  were  compiled  by  the  bureau  and  made  available  for  use  by  the  several 
state  commissions. 

The  collection  and  interpretation  of  the  data  have  been  done  under  the  direc- 
tion of  Professor  H.  W.  Kuhn  of  Ohio  State  University  and  the  report  has  been 
prepared  by  him.  The  tables  presented  add  greatly  to  our  knowledge  of  American 
sickness  experience.] 

To  estimate  the  cost  of  the  cash  benefits  in  a  health  insurance  system 
paying  sickness  and  non-industrial  accident  benefits,  it  is  necessary 
to  determine,  as  accurately  as  may  be,  the  sickness  and  non-industrial 
accident  rates  for  the  groups  of  persons  to  be  insured  over  the  period 
during  which  benefits  are  to  be  paid.  In  this  study  the  experience  of 
organizations  in  the  United  States  is  used  exclusively  in  attempting  to 
determine  these  rates.  It  was  impossible,  of  course,  to  make,  within  one 
year,  a  careful  study  of  all  the  disability  data  available  in  this  country 
and  so  it  was  necessary  to  select  the  group  to  be  studied.  In  making 
this  selection  the  Ohio  Commission  was  fortunate  in  having  the  assis- 
ance  of  representatives  of  the  Connecticut,  Illinois  and  Pennsylvania 
health  insurance  commissions,  as  well  as  that  of  Mr.  Boris  Emmet,  of 
the  United  States  Bureau  of  Labor  Statistics. 

NATURE  OF  THE  DATA  STUDIED. 

The  study  is  divided  into  two  parts.  In  Part  I,  with  the  exception 
of  Table  III,  only  cases  of  sickness  and  non-industrial  accidents  are 
used;  in  Part  II,  cases  of  industrial  accidents  are  also  included. 

Part  I  is  based  upon  a  study  of  13  organizations.  Association  No. 
11,  however,  is  included  only  in  Table  I.  An  intensive  study  was  made 
of  the  experience  of  compensated  cases  in  12  associations.  For  the  pur- 
poses of  this  study  the  experience  of  three  small  associations  is  com- 
bined and  is  represented  by  Association  No.  7  which,  however,  appears 
only  in  Tables  V  and  VI.  The  data  collected  represent  the  experience 
over  a  period  of  3'ears,  varying  from  two  to  five,  in  the  various  associa- 
tions. Nine  of  these  associations  have  their  headquarters  in  Ohio,  one 
in  Illinois,  two  in  Pennsylvania  and  one  in  Connecticut.  The  data  rela- 
tive to  the  associations  were  secured  by  their  own  state  health  insurance 
commissions.     Throughout  the  study  the  number  of  members,  except  in 


319 

Association  N'o.  1/  is  obtained  by  summing  the  annual  average  member- 
ships for  the  years  covered.  The  number  of  cases  is  obtained  in  the 
same  way.  On  this  basis  the  total  membership  of  the  nine  principal 
associations  studied  in  Part  I  is  663,163  and  the  total  number  of  cases 
of  disability  studied  is  131,921.  Only  cases  of  disabilit}'  lasting  eight 
days  or  more  were  studied.  None  of  the  associations  had  a  waiting 
period  longer  than  one  week  and  those  associations  with  a  shorter  wait- 
ing period  than  one  week  are  represented  in  this  study  only  by  cases 
lasting  eight  days  or  more.  The  benefit  associations  studied  in  Part  I 
include  employees  in  the  following  occupations:  railroad  transportation, 
manufacture  of  iron  and  steel  products,  textiles,  general  foundry  work 
and  letter  carrying.  These  occupations  with  the  exception  of  textiles, 
employ  almost  no  women.  The  experience^  therefore,  relates  almost 
entirely  to  men.  One  association,  however,  (No.  8)'  contains  both  men 
and  women  members.  The  distribution  of  cases  of  disability  among 
men  and  women  is  presented  in  Table  IV.  The  information  from 
these  organizations  does  not  lend  itself,  readily  at  least,  to  a  studv 
based  upon  the  age  of  the  members  and  no  attempt  was  made  to  include 
this  important  element. 

Part  II  is  a  study  of  the  data  of  the  Workmen's  Sick  and  Death 
Benefit  Fund,  a  large  association  with  headquarters  in  New  York  City, 
organized  in  1884.  The  data  represent  the  experience  of  the  years  1912 
to  1916  inclusive.  The  number  of  members  and  of  cases,  computed 
as  in  Part  I,  are  respectively  184,985  and  43,488.  The  records  of  this 
association  permit  of  a  study  of  all  cases  of  sickness  lasting  from  one 
day  to  one  year,  as  well  as  of  those  lasting  more  than  seven  days.  It 
was  also  possible  to  tabulate  these  data  so  as  to  show  disability  by  occu- 
pations and  by  ^ge  groups.  It  was  not  possible,  on  the  basis  of  the 
information  furnished,  to  study  sickness  for  each  sex  separately,  but 
from  the  occupations  of  the  members  it  is  evident  that  the  data  relate 
largely  to  men. 

The  study  is  presented  largely  in  table  form  with  some  explanatory 
statements  to  make  their  meanings  clear.  The  tables  are  of  the  follow- 
ing types : 

First — Tables  showing  the  numerical  distribution  of  cases  by  days  of 
disability  (Part  I,  Table  I;  Part  II,  Tables  I  and  II). 

Second — Tables  exhibiting  the  distribution  of  cases  on  a  basis  of 
10,000  cases  for  each  separate  study  and  on  a  basis  of  100,000. cases  for 
the  combined  studies.  Changing  from  the  actual  number  of  cases  to 
10,000  or  100,000  not  only  simplifies  the  study  of  the  separate  distribu- 
tions, but  also  facilities  comparison  and  combination  (Part  I,  Tables 
TI,  III,  IV,  V  and  VI;  Part  II,  Tables  III  and  IV). 

Third — Tables  summarizing  the  important  facts  obtained  from  a 
studv  of  the  material  collected  (Part  I,  Table  VII;  Part  II,  Tables  V, 
VI  and  VII). 

^  Lack  of  time  to  complete  the  tabulations  made  it  necessary  to  determine  the 
membership  of  No.  1  by  the  actual  number  of  cards  handled. 


320 

METHOD. 

All  distributions,  except  one,  shown  in  the  various  tables  are  based 
upon  compensated  cases,  and  this  one  (Part  I,  Table  I,  No.  11)  is  not 
used  in  any  of  the  other  work.  It  should  be  noted,  however,  that  these 
distributions  are  given  with  respect  to  the  actual  number  of  days  dur- 
ation of  the  cases  and  not  with  respect  to  the  compensated  number  of 
days  i.  e.,  the  actual  days  of  disability  for  cases  lasting  eight  days  or 
more  is  given  and  not  merely  the  days  of  disability  after  the  expiration 
of  the  waiting  week. 

A  definite  range  for  all  cases  of  sickness  studied  has  been  used 
throughout  in  calculating  the  average  number  of  days  of  disability  per 
case  and  per  member  per  year.  The  range  chosen  includes  all  cases 
whose  duration  is  eight  days  or  more ;  cases  lasting  longer  than  189  days 
are  included  in  the  189  day  cases.  For  the  cases  of  disability  studied, 
the  days  of  disability  occurring  within  the  first  week  are  included. 
From  the  total  days  of  disability  thus  ascertained,  the  average  number 
of  days  disability  per  member  has  been  determined.  This,  however, 
does  not  present  the  average  days  of  disability  for  cases  of  all  durations, 
but  only  for  cases  lasting  eight  days  and  over,  inclusive  of  disability  up 
to  189  days.  Hence,  it  is  less  than  the  actual  number  of  days  disability 
per  member.  From  the  tables  given  in  Part  I  and  Part  II  it  is  possible 
to  determine  for  other  ranges  the  average  duration  of  disability  per  case 
and  per  member.  It  is  also  possible  to  determine  the  days  which  would 
be  compensated  as  the  result  of  various  waiting  periods  and  lengths  of 
time  for  which  benefit  might  be  payable. 

In  comparing  the  study  made  in  Part  I  with  that  made  in  Part  II, 
it  should  be  noted,  as  stated  above,  that  Part  II  includes  industrial  acci- 
dents, while  Part  I  does  not.  Attention  may  be  dii^cted  to  two  im- 
portant considerations. 

First — The  distribution  of  100,000  cases  of  disability  by  duration  of 
disability  is  slightly  different.  In  Part  I  only  cases  lasting  eight  days 
or  more  have  been  studied;  in  Part  II,  Table  III,  cases  lasting  seven 
days  and  more  are  included.  Notwithstanding  this  slight  variation,  the 
distributions  of  the  cases  of  short  duration  are  in  close  agreement. 

Second— Th.Q  average  number  of  days  of  disability  per  case  and  per 
member  are  not  strictly  comparable  with  the  corresponding  figures  in 
Part  I  since  the  disability  rates  for  the  Workmen's  Sick  and  Death 
Benefit  Fund  include  disability  due  to  industrial  accidents,  while  the  data 
for  the  associations  of  Part  I  do  not.  This  variation  naturally  increases 
the  days  of  disability  per  member  in  the  Workmen's  Sick  and  Death 
Benefit  Fund.  The  rate  for  this  association  is  6.3  days  per  member  per 
year;  the  corresponding  rate  arrived  at  in  Part  I  representing  the  com- 
bined experience  of  the  associations  is  6.0  days.  Inasmuch,  however,  as 
the  membership  of  the  Workmen's  Sick  and  Death  Benefit  Fund  of 
America  includes  relatively  few  workers  engaged  in  really  hazardous 
industries  such  as  iron  and  steel,  construction,  etc.,  the  extent  of  indus- 
trial accidents  among  them  is,  it  is  thought  by  the  tabulators  of  the  data, 
relatively  small.     Eeference  to  the  occupational  classification  of  the  mem- 


321 

bership  shows  that  the  bulk  of  the  members  are  skilled  mechanics  work- 
ing in  relatively  small  establishments.. 

SUMMARY  OF  FINDINGS. 

The  data  presented  in  Parts  I  and  II  show  clearly  that  the  bulk  of 
the  cases  of  disability  are  of  short  duration.  Out  of  100,000  cases  of 
sickness  and  non-industrial  accident  lasting  eight  days  or  more,  inclusive 
of  disability  up  to  189  days,  34,660  lasted  from  eight  to  14  days  (Part 

I,  Table  VI)  ;  out  of  100,000  cases  of  sickness,  non-industrial  accident 
and  industrial  accident  combined,  34,321  lasted  seven  to  13  days  (Part 

II,  Table  III).  The  cases  of  short  duration  are  so  numerous  that  not- 
withstanding the  shorter  duration  per  case,  the  cases  of  short  duration 
account  for  more  days  of  disability  than  the  smaller  number  of  longer 
cases.  For  example  34,660  cases  lasting  eight  to  14  days  account  for 
381,260  days  of  disability  (including  the  first  seven  days  )  ;  19,516  cases 
lasting  15  to  21  days  account  for  but  351,288  days  of  disability.  These 
two  groups  of  cases  account  for  20.7  per  cent  of  all  the  days  disability 
among  cases  lasting  eight  days  or  more,  inclusive  of  disability  up  to  189 
days.  This  fact  has  the  ntmost  significance  for  a  system  of  health  insur- 
ance. It  means  that  the  compensation  of  the  relatively  small  number 
of  cases  of  long  duration,  for  which  compensation  is  most  needed,  does  not 
increase  the  expenditure  for  cash  benefits  in  proportion  to  the  days 
duration  per  case. 

An  analysis  of  the  distribution  of  10,000  cases  each  of  sickness  and 
of  non-industrial  accident  in  the  same  associations  (N'os.  6  and  4)  shows 
similiar  distributions  (Part  I,  Table  II).  Analysis  of  10,000  cases  each 
of  sickness  and  non-industrial  accident  combined  and  of  industrial  acci- 
dent from  the  records  of  another  association  (No.  1)  again  shows  sim- 
ilar distributions  (Part  I,  Table  III).  It  is  probable,  therefore  that  the 
inclusion  of  industrial  accidents  in  the  data  of  Part  II  does  not  greatly 
affect  the  distribution  of  cases  as  compared  with  the  distribution  in 
Part  I  (Part  I,  Table  VI;  Part  II,  Table  III). 

The  distribution  of  10,000  cases  of  sickness  and  non-industrial  acci- 
dent by  duration  among  males  and  among  females  in  the  same  associa- 
tion (Xo.  8)  shows  that  a  larger  proportion  of  the  cases  among  the 
males  are  of  shorter  duration  than  among  females  (Part  I,  Table  IV). 
For  example,  out  of  10,000  cases  among  males  4,098  lasted  eight  to 
14  days;  out  of  10,000  cases  among  females  only  2,773  cases  lasted  eight 
to  14  days.  The  records  of  this  association  also  show  that  the  average 
days  of  disability  per  year  are  greater  for  women  than  for  men.  The 
average  number  of  days'  disability  per  member  per  year  (based  upon 
the  cases  lasting  eight  da3^s  or  more  inclusive  of  disability  up  to  189 
days)  is  much  higher  in  this  association  than  in  any  other  studied. 
This  is  due  in  part  to  the  large  number  of  women  members  and  to  the 
liberal  treatment  accorded  them. 

The  combined  data  of  Part  I  indicates  that  in  the  course  of  a  year 
19.7  per  cent  of  the  members  of  the  nine  principal  associations  are  dis- 
abled bv  sickness  and  non-industrial  accident  for  eight  days  or  more 
(Part  I,  Table  VII).     The  data  for  the  Workmen's  Sick  and  Death 

—21  H  I 


322 

Benefit  Fund  show  that  in  the  course  of  a  year  16.9  per  cent  of  the 
members  are  disabled  for  eight  days  or  more  as  a  result  of  sickness, 
non-industrial  and  industrial  accident  (Part  II,  Table  V),  and  that  23.5 
per  cent  are  similarly  disabled  for  one  day  or  more  (Part  II,  Table  IV). 

Data  in  both  Part  I  and  Part  II  give  the  average  days  of  disability 
per  case.  In  the  nine  principal  associations  the  average  duration  per 
100,000  cases  of  sickness  and  non-industrial  accidents  combined  lasting 
eight  days  and  over,  inclusive  of  disability  up  to  189  days,  is  35.3  per 
case  (Part  I,  Table  YI).  In  part  II  the  average  duration  per  case  (in- 
clusive of  industrial  accident)  lasting  eight  days  or  over,  inclusive  of 
disability  up  to  189  days,  is  37.2  days  (Part  II,  Table  V). 

The  average  number  of  days  disability  per  member  per  year  (based 
on  cases  lasting  eight  days  or  more,  inclusive  of  disability  up  to  189 
da3^s)  is  6.0  days  for  the  nine  principal  associations  studied  in  Part  I 
(Part  I,  Table  VI)  ;  the  average  days  of  disability  (inclusive  of  indus- 
trial accidents)  is  6.3  days  per  member  per  year  for  the  Workmen's 
Sick  and  Death  Benefit  Fund  (Part  II,  Table  VI).  Information  from 
the  Workmen's  Sick  and  Death  Benefit  Fund  for  compensated  cases  of 
disability  (inclusive  of  industrial  accidents)  lasting  one  day  and  over, 
inclusive  of  disability  up  to  one  year,  makes  it  possible  to  compute  more 
closely  the  total  days  of  disability  per  member  per  year.  The  relatively 
small  number  of  cases  lasting  less  than  seven  days  sls  compared  with 
those  lasting  seven  days  and  over  indicates  that  the  compensated  cases 
lasting  less  than  seven  days  are  probably  below  the  actual  number  (See 
also  Part  I,  Table  I,  Association  Xo.  11),  and  hence  that  the  estimated 
average  days  disability  per  member  per  year  are  below  the  actual  days 
of  disability.  Subject  to  these  qualification,  the  data  indicate  that  each 
member  is  compensated  on  the  average  for  6.9  days  of  disability  a  year 
and  that  each  member  is  disabled  on  the  average  at  least  6.9  days  a  j^ear. 

Study  of  disability  by  occupation  and  age  is  possible  from  the  data 
of  the  Workmen's  Sick  and  Death  Benefit  Fund.  Unfortunately,  ac- 
curate comparison  of  sickness  in  the  various  occupations  covered  is  im- 
possible because  of  the  inclusion  of  disability  due  to  industrial  accidents, 
a  hazard  which  varies  from  occupation  to  occupation.  As  a  result  in 
one  occupation  a  larger  proportion  of  disability  days  will  be  due  to 
industrial  accident  than  in  another.  For  example,  among  the  724  freight 
handlers,  the  average  days  of  disability  per  year  (based  on  cases  lasting 
eight  days  or  more,  inclusive  of  disability  up  to  189  days)  is  9.2  days 
per  person.  Undoubtedly  among  the  freight  handlers  disability  due  to 
industrial  accidents  accounts  for  a  considerable  proportion  of  the  days 
of  disability  (Part  II,  Table  V). 

Data  showing  the  days  of  disability  by  age  groups  are  much  more 
comparable  because  the  accident  hazard  does  not  vary  so  greatly  from 
age  group  to  age  group. With  increase  in  age,  the  duration  of  disability 
per  case  and  per  member  increases  regularly.  For  example  persons  20 
to  24  years  of  age  are  disabled  on  an  average  of  4.2  per  year;  those 
between  50  and  54  years  of  age,  7.3  days  a  j^ear  (Part  II,  Table  VI). 

The  days  of  disability  per  member  sick  eight  days  and  over,  exclu- 
sive of  the  first  seven  days  and  of  disability  days  beyond  189,  for  which 
no  benefit  is  paid,  are  referred  to  as  the  average  compensated  days  per 


323 

member.  For  the  associations  studied  in  Part  I,  the  average  compen- 
sated days  per  member  arrived  at  are  4.8  (Part, I,  Table  VI)  ;  for  the 
Workmen's  Sick  and  Death  Benefit  Fund,  5.1  days  per  member  (Part 
11,  Table  V). 

From  the  data  studied  it  is  possible  to  estimate  the  number  of  com- 
pensated days  for  which  an  obligatory  system  of  health  insurance,  pay- 
ing benefits  for  26  weeks  after  the  first  seven  days,  would  be  liable. 
Allowing  a  margin  of  25  per  cent,  the  minimum  number  of  compensated 
days  per  member  per  year,  under  these  conditions,  would  be  6.0  days. 

By  reason  of  the  rather  large  amount  of  material  used  and  also 
by  reason  of  its  careful  selection  and  wide  occupational  distribution, 
the  results  arrived  at  are  believed  to  be  fairly  trustworthy.  Studies  of 
the  kind  herein  contained  are  of  value  not  only  to  members  of  the  com- 
missions and  others  Avho  are  considering  the  advisability  of  adopting  a 
health  insurance  system  but  also  to  those  in  charge  of  existing  systems 
of  insurance.  More  comprehensive  studies  of  the  same  kind  for  sick- 
ness, for  non-industrial  accidents  and  for  industrial  accidents  separately, 
when  based  on  the  ages  of  the  members,  sex,  occupation,  etc.,  are  needed. 

PAET  I.  A  DETERMINATIOJST  OF  THE  SICKNESS  AND  NON- 
IXDUSTRIAL  ACCIDENT  EATE  APPLICABLE  TO  A  STATE 
SYSTEM  OF  HEALTH  INSURANCE  BASED  UPON  A 
STUDY  OF  A  SELECTED  GROUP  OF  BENEFIT  ASSOCIA- 
TIONS IN  THE  UNITED  STATES. 

TABLE  I — NUMBER  OF  CASES  OF  SICKNESS  AND  NON-INDUSTRIAL  ACCI- 
DENTS, BY  DURATION  IN  DAYS.     ASSOCIATIONS  2,   10  AND  11. 


Number  of  cases. 

Duration  in  days. 

No.  2. 

No.  10. 

No.  11. 

7 

4,764 

4,359 

4,287 

4,079 

3,584 

3,214 

2,982 

3,019 

2,152 

2,025 

1,691 

1,551 

1,365 

1,182 

1,274 

939 

903 

842 

689 

624 

596 

643 

511 

509 

461 

413 

365 

393 

409 

8 

15 
27 
44 
55 
85 
97 
110 
110 
105 
87 
83 
77 
58 
88 
84 
72 
65 
60 
46 
45 
37 
49 
37 
43 
44 
41 
32 
22 

939 

9 

733 

10 

6a3 

11 

528 

12 

615 

13 

371 

14 

364 

15 

245 

16 

295 

17 

183 

18 

214 

19 

117 

20 

125 

21 

22 

23 

\       468 

24 

25 

26 

' 

27 

28 

I   286 

29 

30 

31 

< 

32 

33 

\       250 

34 

35. .f 

Duration  in  days. 


Number  of  cases. 


No.  2. 


No.  10. 


No.  11. 


36 
37 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
50 
51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 


308 

24 

285 

26 

277 

31 

. 

283 

21 

233 

29 

260 

35 

268 

26 

185 

26 

• 

206 

16 

217 

25 

212 

21 

204 

10 

183 

15 

190 

11 

168 

17 

167 

19 

172 

15 

129 

11 

. 

139 

16 

127 

8 

159 

17 

110 

11 

123 

8 

114 

17 

96 

13 

131 

9 

123 

9 

124 

12 

94 

10 

132 


166 


74 


63 


48 


37 


324 


TABLE  I — Continued. 


Number  of  cases. 

Duration  in  days. 

No.  2. 

No.  10. 

No.  11. 

65 

79 
117 
85 
74 
64 
89 
78 
63 
77 
58 
55 
62 
71 
60 
52 
64 
58 
58 
58 
52 
48 
66 
51 
44 
59 
51 
51 
67 
40 
42 
34 
49 
36 
48 
51 
40 
34 
35 
32 
36 
45 
28 
28 
30 
27 
27 
40 
27 
20 
27 
36 
27 
25 
29 
26 
38 
24 
32 
26 
14 
21 
19 
17 
20 
16 
24 
24 
10 
13 
21 
17 
20 

6 
5 
12 
11 
10 
5 
2 
6 
12 
5 
4 
8 
4 
3 
6 
9 
6 
7 
5 
5 

10 
2 
7 
3 
4 
5 
1 
7 
1 
1 
2 
5 
5 
8 
3 
3 
4 
6 
1 
5 
3 
2 
8 
4 
2 
2 
4 
1 
2 
4 
4 
4 

37 

66 

1 

67 

68 

I    19 

69 

70 

71 

' 

72 

73   

38 

74 

75 

76 

■ 

77 

78 

I   30 

79 

80 

81 

' 

82 

83  

I    10 

84 

85 

86 

■ 

87  

88 

i    11 

90 

91 

' 

92 

10 

94 

96 

' 

97 

98 

i   11 

100 

101 

*97 

102 

104 

105 

106 

108 

110 

Ill 

112 

113 

114 

116 

117 

118 

3 

1 
1 

1 

119 

120 

122 

2 
1 

1 
3 

124 

125 

126 

128 

130 

4 
4 

131 

132 

1 
1 
2 

1 

134 

136 

Number  of  cases. 


Duration  in  days 


137 

20 

12 

12 

10 

14 

13 

13 

10 

13 

16 

16 

13 

13 

10 

8 

12 

10 

9 

8 

11 

8 

19 

15 

11 

8 

9 

8 

8 

9 

13 

5 

13 

6 

9 

7 

8 

6 

11 

8 

6 

4 

8 

7 

3 

10 

10 

11 

5 

9 

9 

4 

6 

16 

5 

5 

5 

8 

7 

6 

8 

10 

5 

5 

4 

4 

10 

4 

6 

5 

2 

6 

5 

1 

138 

139 

3 
2 
1 

1 

140 

141 

142 

143 

144 

145 

1 

1 
3 

146 

147 

148 

149 

1 
2 
2 
1 
2 
1 
2 
2 

150 

151 

152 

153 

154 

155 

156 

157 

158 

1 
1 
1 
1 

1 

159 

160 

161 

162 

163 

164 

1 

165 

166 

167 

1 

168 

169 

1 
1 

170 

171 

172 

173 

1 

174 

175 

3 

176 

177 

1 

178 

179 

180 

1 

181 

182 

2 

183 

184 

185 

186 

187 

1 

188 

189 

1 

190 

191 

2 

1 
1 
1 

192 

193 

194 

195 

196 

197 

198 

199 

2 

200 

201 

2 
2 

202 

203 

204 

205 

206 

2 

207 

208 

1 

325 


TABLE  I — Continued. 


Number  of  cases. 

Duration  in  days. 

No.  2. 

No.  10. 

No.  11. 

209 

5 

5 

6 

1 

6 

6 

3 

5 

8 

2 

9 

4 

6 

3 

5 

6 

4 

3 

7 

6 

3 

3 

3 

7 

4 

6 

3 

4 

2 

4 

3 

3 

2 

3 

5 

2 

4 

4 

3 

4 

1 

5 

4 

3 

3 

2 

3 

3 

3 

2 

4 

4 

2 

2 

3 

1 

4 

2 

3 

2 

4 

4 

5 

5 

7 

2 

3 

6 

1 

3 

2 

6 

2 

210 

211 

212 

213 

214 

2 
1 
2 

215 

216 

217 

218 

1 

219 

220 

1 
1 

1 

221 

222 

223 

224 

225 

1 

226 

227 

1 

228 

229 

1 

231 

232 

"  ■ ■ 



233 

234 

-1 

1 

235 

236 

237 

238 

239 

2 

240 

241 

243 : 

244 

245 

1 
1 
1 

246 

247 

248 

249 

1 

250 

251 

252 

2 

253 

254 

255 

1 

256 

257 

258 

259 

1 

261 

262 

263 

264 

265 

1 
1 

267 

268 

269 

1 
1 

1 

270 

271 

272 

273 

1 
1 

274 

275 

276 : 

277 

278 

1 

279 

Duration  in  days. 

Number  of  cases. 

No.  2. 

No.  10. 

No.  11. 

281 

2 
2 
4 
3 
1 
3 
2 
2 
5 
4 
3 
9 
2 
4 
2 
1 
3 
6 
2 
3 
2 
5 
2 

282 

283 

1 

284 

285 

286 

287 

288 

289 

290 

291 

1 
2 

292 

293 

294 

295 

296 

297 

298 

299 

300 

I 

301 

302 

303 

304 

305 

4 
2 
2 
4 
3 
2 
3 
4 
7 
5 
4 
1 
3 
2 
5 
4 
2 
4 
4 
3 
1 
4 
2 
4 
1 
3 
5 
5 
4 
2 
6 
3 
2 
1 
3 
4 
4 
1 
1 
4 
4 
4 
3 
6 
4 
5 
7 
10 

306 

1 

307 

308 

309 

1 

310 

311 

312 

313 .  .. 

314 

1 


315 

316 

317 

318 

319 

320 

1 

1 

321 

322 

323  

324 

325 

326 

1 

327 

328 

329             .  . 

330    

331 

332             .  . 

333           

334       

335  

336 

337         

338 

1 
1 

339 

340 

341          .   .  .. 

342         

343 

1 

344 

345 

346            

347 

1 

348 

349            .  .. 

350           

351    .     

352 

326 


TABLE  I — Concluded. 


Number  of  cases. 

Duration  in  days. 

No.  2. 

No.  10. 

No.  11. 

353 

2 
4 
5 
5 
3 
8 

354 : 

1 

355 

356              

357      

358 

359 

Number  of  cases. 

Duration  in  days. 

No.  2. 

No.  10. 

No.  11. 

360 

6 
4 
7 
2 
9 
694 

361 

362 

363 

364 

365 

76 

♦  This  number  includes  cases  lasting  100  days  or  more. 

The  distribution  of  compensated  cases  under  Xo.  2  and  Xo.  10  illus- 
trate two  t}^es  that  occur  among  the  establishment  funds  studied.  In 
Xo.  2  the  number  of  cases  decreases  in  a  fairly  uniform  manner  as  the 
number  of  days  duration  increases.  In  Xo.  10  the  number  of  cases  first 
increases  as  the  number  of  davs  duration  increases  from  7  to  14,  and 
then  decreases.  The  distributions  in  Xo.  11  include  all  cases  of  sick- 
ness and  non-indrretrial  accidents  (compensated  and  non-compensated) 
for  a  large  manufacturing  concern  in  Ohio  that  is  unusually  well  organ- 
ized for  collecting  accurate  data.  It  will  be  noticed  that  Xo.  2  and  Xo. 
11  agree  in  type. 

The  distributions  in  Table  I  illustrate  the  form  in  which  the  data 
used  in  this  report  were  tabulated. 

In  the  rest  of  Part  I  only  compensated  cases  of  sickness  and  non- 
industrial  accidents  are  used. 


327 

TABLE  it— DISTRIBUTION  OF  10,000  CASES  EACH  OP  SICKNESS,  OP  NOl^- 
INDUSTRIAL  ACCIDENTS,  AND  OP  SICKNESS  AND  NON-INDUSTRIAL 
ACCIDENTS,  BY  DURATION  IN  DAYS.     ASSOCIATIONS  NO.   6  AND  4. 


Case  distribution  per  10,000  cases. 

Number  6. 

Number  4. 

Duration  in  days. 

Sickness 
(based 

on  4,975 
cases). 

Non-in- 
dustrial 
accidents 
(based  on 
1,622 
cases). 

Sickness 
and  non- 
industrial 
accidents 
(based  on 
6,597  cases). 

Sickness 

(based 

on  7,682 

cases). 

Non-in- 
dustrial 
accidents 
(based  on 
826  cases). 

Sickness 
and  non- 
industrial 
accidents 
(based  on 
8,508  cases). 

8-  14 

2,324 

2,072 

1,322 

856 

689 

442 

376 

281 

235 

193 

161 

175 

129 

129 

92 

74 

88 

33 

56 

35 

48 

23 

22 

18 

16 

108 

3,083 

1,954 

1,202 

968 

771 

419 

308 

259 

197 

80 

173 

117 

55 

62 

38 

43 

18 

43 

32 

31 

7 

18 

18 

6 

62 

18 

2,510 

2,043 

1,293 

890 

709 

437 

359 

276 

226 

165 

164 

161 

111 

112 

79 

67 

71 

35 

50 

33 

38 

21 

21 

15 

27 

87 

4,223 

1,838 

914 

612 

444 

310 

212 

144 

113 

108 

195 

76 

61 

49 

42 

34 

26 

26 

26 

20 

20 

20 

18 

17 

17 

435 

4,770 

1,731 

1,017 

654 

448 

339 

242 

85 

133 

73 

97 

73 

48 

24 

24 

24 

12 

12 

12 

12 

12 

1 

12 

12 

12 

121 

4,276 

15-  21 

1,828 

22-  28 

924 

29-35 

616 

36-42 

445 

43-49 

313 

50-56 

215 

57-63 

139 

64-  70 

115 

71-  77 

105 

78-  84 

185 

85-  91 

75 

92-  98 

60 

99-105 

47 

10&-112 

40 

113-119 

33 

120-126 

25 

127-133 

25 

134-140 

24 

141-147 

19 

148-154 

18 

155-161 

19 

162-168 

18 

169-175 

16 

176-182 

16 

183-189 

404 

Total 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

328 

TABLE  III— DISTRIBUTION  OF  10,000  CASES  EACH  OF  INDUSTRIAL  ACCt- 
DENTS  AND  OP  SICKNESS  AND  NON-INDUSTRIAL  ACCIDENTS,  BY 
DURATION  IN  DAYS.     ASSOCIATION  NO.   1. 


Case  distribution 
10,000  cases. 

per 

Duration  in  days. 

Industrial 

accidents 

(based  on 

13,308  cases). 

Sickness  and 
non-indus- 
trial accidents 
(based  on 

37,615  cases). 

8-14 

4,997 

1,911 

892 

579 

356 

293 

186 

132 

94 

69 

59 

54 

29 

40 

33 

22 

23 

23 

21 

16 

15 

16 

10 

9 

8 

6 

107 

5,573 
1,830 

15-21 

22-28 

770 

29-36 

415 

37-42 

290 

43-49 

203 

50-56 

156 

57-63 

120 

64-70 

86 

71-77 

72 

78-84 

55 

85-91 

54 

92-98 

33 

99-105 

40 

106-112 

37 

11.^119 

21 

120-126 

22 

127-133 

15 

134-140 

12 

141-147 

13 

148-154 

10 

155-161 

9 

162-168 

12 

169-175 ...                 .       ..  . 

6 

176-182 

7 

183-189 

7 

190-      

132 

Total : 

10,000 

10,000 

329 


TABLE  IV^DISTRIBUTION  OF  10.000  CASES  OF  SICKNESS  AND  NON- 
INDUSTRIAL  ACCIDENTS  FOR  MALES.  FOR  FEMALES  AND  FOR  MALES 
AND  FEMALES.    BY  DURATION   IN  DAYS.     ASSOCIATION   NO.    8. 


Case  distribution  per  10,000  oases. 

Duration  in  days, 

• 

Males 
(based  on 
815  cases). 

Females 

(based  on 

1,006  cases). 

Males  and 

females 

(based  on 

1,821  cases). 

8-14 

4,098 

1,988 

908 

564 

368 

245 

221 

243 

209 

147 

86 

86 

49 

74 

37 

25 

74 

37 

25 

61 

12 

25 

25 

25 

37 

37 

294 

2,773 

1,849 

1,113 

626 

487 

457 

378 

199 

209 

139 

139 

159 

139 

89 

159 

50 

60 

60 

88 

50 

30 

40 

60 

40 

20 

30 

557 

3,366 

15-21 

1,911 

22-28 

1,021 

29-36 

599 

37-42 

434 

43-49 

362 

50-56 

308 

57-63 

217 

64-70 

209 

71-77 

143 

78-84 

115 

85-91 

126 

92-  98 

99 

99-105 

82 

106-112 

104 

113-119 

.38 

120-126 ; 

66 

127-133 

49 

134-140 

60 

141-147 

55 

148-154 

25 

155-161 

33 

162-168 

44 

169-175 

33 

29 

183-189 

33 

439 

10,000 

10,000 

10,000 

# 

330 


'tABLE  V— DISTRIBUTION  OP  10,000  CASES  OF  SICKNESS  AND  NO^- 
INDUSTRIAL  ACCIDENTS,  BY  DURATION  IN  DAYS  AND  BY  ASSOCIA- 
TIONS.    TWELVE  BENEFIT  ASSOCIATIONS. 


Case  distribution  per  10,000  cases. 

No.  1. 

No.  2. 

No.  3. 

No.  4. 

No.  5. 

No.  6. 

No.  7.* 

No.  8. 

No.  9. 

No.  10. 

Duration  in  days. 

CO 

OS  OS 

■^  ■ 

00^ 

g-og 

®  JS  o 

IS  5?  c 

S3 

OS 

en  2 
C8  «? 

00 
00 

a 

6 

CO    1 

CO  u-^ 

S"S - 
003 

cO~ 

CS  53 

05 

Oi 

g^ 

1—4 

00 

1—1 

g^ 
%^ 

CO 
cS  03 

0 

Oi 
CO^ 

«i 

tn  52 

03   03 

8-14 

5,573 

1,830 

770 

415 

290 

203 

156 

120 

86 

72 

55 

54 

33 

40 

37 

21 

22 

15 

12 

13 

10 

9 

12 

6 

7 

7 

132 

4,612 

2,031 

946 

553 

346 

252 

192 

148 

109 

84 

73 

67 

57 

49 

37 

34 

31 

22 

20 

17 

15 

14 

12 

10 

9 

11 

249 

4,474 

1,690 

893 

683 

326 

336 

273 

210 

95 

116 

106 

88 

66 

62 

55 

46 

35 

31 

22 

28 

20 

19 

18 

17 

16 

15 

260 

4,276 

1,828 

924 

616 

445 

313 

215 

139 

115 

105 

185 

75 

60 

47 

40 

33 

71 

25 

24 

19 

18 

19 

18 

16 

16 

14 

390 

3,472 

1,714 

1,176 

791 

602 

394 

337 

240 

205 

164 

135 

127 

100 

60 

45 

34 

66 

25 

22 

20 

17 

16 

15 

13 

13 

12 

221 

2,510 

2,043 

1,293 

890 

709 

437 

359 

276 

226 

.165 

164 

161 

111 

112 

79 

67 

71 

35 

50 

33 

38 

21 

21 

15 

27 

20 

67 

2,383 

1,937 

1,491 

783 

533 

609 

468 

185 

294 

174 

98 

141 

98 

65 

44 

44 

33 

44 

11 

22 

53 

33 

0 

11 

22 

11 

413 

3,366 

1,911 

1,021 

599 

434 

362 

308 

217 

209 

143 

115 

126 

99 

82 

104 

38 

66 

49 

60 

55 

25 

33 

44 

33 

29 

33 

439 

2,384 

2,272 

1,289 

785 

448 

433 

357 

280 

188 

173 

137 

132 

87 

102 

66 

61 

51 

46 

46 

66 

31 

41 

36 

15 

31 

51 

392 

1,610 

15-  21 

2,260 

22-28 

1,520 

2^  35 

996 

36-  42 

714 

43-49 

461 

50-  56 

383 

67-63 

294 

64-  70 

219 

71-  77 

153 

78-84 

152 

8^  91 

119 

92-98 

108 

99-105 

93 

106-112 

86 

113-119 

67 

120-126 

34 

127-133 

33 

134-140 

37 

141-147 

26 

148-154 

33 

155-161 

30 

162-168 

11. 

169-175 

22 

176-182 

15 

183-189 

8 

190-      

516 

Total 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

I 


•  Distribution  No.  7  is  the  combination  of  the  distributions  given  by  three  rela- 
tively small  associations,  each  of  which  is  organized  and  administered  in  such,  a 
way  as  to  give  trustworthy  results. 

Further  information  concerning  nine  of  these  benefit  associations 
is  given  in  Table  VII. 

For  the  purpose  of  obtaining  from  the  combined  experience  of  these 
12  associations,  figures  representative  of  sickness  among  the  industrial 
population,  it  was  decided  not  to  weight  in  proportion  to  the  members 
exposed  because  this  would  have  given  undue  weight  to  the  sickness 
experience  in  certain  occupations  heavily  represented  in  the  associations 
studied  but  not  of  equal  numerical  importance  in  the  industrial  popula- 
iton.  In  combining  them,  the  experience  of  each  association  was  given 
equal  value.     This  leads  to  the  first  part  of  Table  VI. 


^31 


'TABLE  VI— DISTRIBUTION  OF  100,000  CASES  OF  SICKNESS  AND  NON- 
INDUSTRIAL  ACCIDENTS,  BY  DURATION  IN  DAYS.  COMBINED  EXPE- 
RIENCE OF  TWELVE  BENEFIT  ASSOCIATIONS. 


All  cases. 

Duration  in  days. 

Case 

distribution 

per  100,000 

cases 

(based  on 

132,840 

cases). 

Number 

of  days  of 

disability 

per  100,000 

cases. 

Accumu- 
lated days 
of  disability 
per  100,000 
cases. 

8-14 

34,660 

19,516 

11,323 

7,111 

4,847 

3,800 

3,048 

2,109 

1,746 

1,349 

1,220 

1,090 

819 

712 

593 

445 

398 

325 

304 

299 

260 

235 

187 

158 

185 

182 

3,079 

381,260 

351,288 

283,075 

227,552 

189,033 

174,800 

161,544 

126,540 

116,982 

99,826 

98,820 

95,920 

77,805 

72,624 

64,637 

51,620 

48,954 

42,2.50 

41,648 

43,056 

39,260 

.37,130 

30,855 

27, 176 

33, 115 

33,852 

581,931 

381,260 

15-21 

732,548 
1,015,623 
1.243,175 

22-28 

29-35 

36-42 

1,432,208 
1,607,008 

43-49 

50-56 

1, 768, 552 

57-63 

1,895,092 

64-70 

2,012,074 

71-77 

2,111,900 

78-84 

2,210,720 
2,306,640 

85-91 ' 

92-98 

2,384,445 

99-105 

2,457,069 

106-112 

2,521,706 

113-119 

2,573,326 

120-126 

2,622,280 

127-133 

2,664,530 

134-140 

2,706,178 

141-147 

2,749,234 

148-154 

2,788,494 

155-161 

2,825,624 

162-168 

2,856,479 

169-175 

2,883,655 

176-182 

2,916,770 

183-189 

2,950,622 

190-      

3,532,553 

Total 

100,000 

3, 532, 553 

332 


TABLE  VI — Concluded. 


I 


Duration  in  days. 


Cases  lasting  190  days  and  over. 


Case 
distribu- 
tion per 
100,000 
cases. 


Number  of 

days 

of  disability 

per  100,000 

cases. 


Accumu- 
lated days 
of  disability 
per  100,000 
cases. 


190-196.. 

197-203.. 

204-210. . 

211-217.. 

218-224.. 

225-231.. 

232-238.. 

239-245. . 

246-252. . 

253-259.. 

260-266. . 

267-273.. 

274-280.. 

281-287.. 

28^294.. 

295-301.. 

302-308.. 

309-315.. 

316-322. . 

323-329... 

330-336... 

337-343... 

344-350... 

351-357... 

358-363... 

364-371... 

372-   . . . 

Total 


127 

24,511 

114 

22,800 

102 

21,114 

98 

20,972 

91 

20,111 

82 

18,696 

78 

18,330 

73 

17,666 

77 

19, 173 

69 

17,664 

64 

16,832 

77 

20, 790 

.   64 

17,728 

59 

16,756 

57 

16,587 

61 

18, 178 

59 

17,995 

62 

19,344 

55 

17, 545 

55 

17,930 

57 

18,981 

50 

17,000 

48- 

16,656 

53 

18,762 

55 

19,855 

64 

23,552 

1,228 

455, 588 

3,079 

951,116 

2, 975, 133 
2,997,933 
3,019,047 
3,040,019 
3,060,130 
3,078,826 
3,097,156 
3,114,822 
3,133,995 
3,151,659 
3, 168, 491 
3, 189, 281 
3,207,009 
3,223,765 
3,240,352 
3, 258, 530 
3, 276, 525 
3, 295, 869 
3,313,414 
3,331,344 
3,350,325 
3,367,325 
3,383,981 
3,402,743 
3,422,598 
3,446,150 
3,901,738 


The  second  part  of  this  table  distributes  the  3,079  cases  in  the  first 
part,  that  last  longer  than  189  days,  through  the  following  26  weeks. 
The  distribution  of  these  cases  was  based  upon  the  distributions  (slightly 
smoothed)  given  by  six  of  the  ten  benefit  associations  used  in  forming 
Table  V. 

The  number  of  days  of  disability  for  a  given  week  was  determined 
by  finding  the  product  of  the  number  of  cases  by  the  average  number 
of  days  duration  for  that  week  (c.  g.,  381,260==:34,660Xli). 

It  is  to  be  noted  that  the  average  duration  in  days  per  case  as  given 
by  the  distribution  in  the  first  part  is  about  35.3  while  thai:  given  by  the 
distribution  in  both  parts  is  slightly  greater  than  39. 


333 


TABLE    VII — AVERAGE    DURATION    OF    DISABILITY    IN    DAYS    PER    CASE 
AND    IN   DAYS   PER   MEMBER.     NINE    BENEFIT   ASSOCIATIONS. 

(The  figures  are  based  on  cases  lasting  8  days  or  more  ;  the  cases  lasting  more  than 

189  days  are  counted  as  189  day  cases.) 


Benefit  associations. 


Years 
covered. 


Number 
of  cases. 


Number 

of 
members. 


Number 
of  days  of 
dis- 
ability. 


Average 
compen- 
sated 
days  per 
member. 


Average  days  of 
disability. 


Per 

case. 


Per 
member. 


Number  1 . 
Number  2 . 
Number  3 . 
Number  4. 
Number  5. 
Number  6 . 
Number  8. 
Number  9. 
Number  10. 

Total... 


1913-1917 

37,615 

*115,648 

873,818 

5.3 

23.2 

1913-1917 

t55,343 

276, 119 

1,574,982 

4.3 

28.5 

1915-1917 

952 

6,187 

29, 481 

3.7 

31.0 

1915-1917 

8,508 

70,697 

280,411 

3.1 

33.0 

1916-1917 

tl6,432 

100,000 

557,065 

4.4 

33.9 

1915-1917 

6,597 

47,605 

241,521 

4.1 

36.6 

1916-1917 

1,821 

6,946 

73,872 

8.8 

40.6 

1914-1916 

1,963 

13,019 

82,363 

5.3 

41.9 

1912-1916 

2,690 

26,942 

117,023 

3.6 

43.5 

131,921 

663,163 

3,830,536 

4.4 

29.0 

7.6 
5.7 
4.8 
3.9 
5.6 
5.1 
10.6 
6.3 
4.4 


5.8 


*  Membership  is  determined  on  the  basis  of  cards  actually  handled. 
t  Cases  of  disability  do  not  include  non-industrial  accident. 

The  number  of  days  of  disability  was  determined  from  distributions 
illustrated  by  those  given  in  Table  I. 

Information  concerning  the  membership,  the  organization  and  other 
conditions  pertaining  to  these  associations,  along  with  the  distributions 
illustrated  by  Table  I,  leads  one  to  conclude  that  one  (at  least)  of  the 
sickness  rates  in  the  last  column  is  abnormally  high,  Avhile  some  others 
are  abnormally  low.  The  high  rate  for  No.  8  is  due  to  the  fact  that  this 
association  contains  a  large  percentage  of  females  in  its  membership 
and  the  organization  has  been  liberal  in  its  treatment  of  them.  One 
sickness  rate  is  too  low  on  account  of  the  fact  that  the  percentage  of 
cases  of  short  duration  is  altogether  too  small.  Another  is  too  low 
because  some  of  the  members  take  their  vacation  during  illness:  they 
are  given  better  pay  during  the  vacation  period  allowed  than  they  would 
get  by  claiming  sickness  benefits  from  the  association.  These  three 
cases  just  cited  are  illustrations  of  the  fact  that  full  information  of  all 
conditions  that  pertain  to  a  given  organization  is  needed  before  a  fairly 
accurate  estimate  can  be  formed  of  the  value  of  its  sickness  rate. 

The  study  of  the  Ohio  establishment  funds  which  the  writer  of  this 
chapter  of  the  report  made  last  spring  and  summer  leads  him  to  conclude 
that  what  may  be  termed  the  administrative  part  of  these  benefit  asso- 
ciations is  an  important  factor  and  needs  careful  consideration.  Under 
administrative  part  it  is  meant  to  include  not  merely  the  attitude  of  the 
officers  in  enforcing  the  regulations  of  the  association  but  also  the  atti- 
tude of  the  members  in  applying  for  benefits. 

If  the  above  sickness  rates  are  given  equal  weight  in  combining 
them,  a  sickness  rate  of  6.0  days  results  for  the  period  stated.  If  these 
sickness  rates  are  given  weights  equal  to  the  number  of  members  in- 
volved in  each  determination,  a  sickness  rate  of  5.8  days  results.  If 
Association  No.  1,  the  data  for  which  are  incomplete,  is  omitted,  the 
corresponding  numbers  are  5.8  and  5.4  respectively.     But,   as  it  has 


334 

m  stated  above,  the  unweighted  average  gives  what  is  believed  to  be 
a  more  representative  experience.  The  average  number  of  compensated 
days  per  member  can  be  easily  ascertained  from  the  average  number  of 
days  disability  per  member.  The  total  number  of  days  of  disability  per 
100,000  cases,  3,523,553,  is  divided  by  6  days  to  ascertain  the  number 
of  members.  The  number  of  members  thus  ascertained  is  588,759.  If 
the  waiting  period  of  seven  days  of  disability  for  each  of  the  100,000 
cases  is  subtracted  from  the  total  days  of  disabilit}^  3,532,553,  the  re- 
mainder is  2,832,553,  or  the  number  of  days  for  which  benefit  is  paid. 
The  total  compensated  days  divided  by  the  number  of  members  gives 
the  average  compensated  days  per  member,  or  4.8  days. 

In  the  judgment  of  the  writer^  considering  all  facts  in  hand,  the 
following  conclusion  may  be  drawn :  the  study  made  in  this  part  shows 
that  the  average  number  of  days  each  member  of  the  organizations 
investigated  was  disabled  each  year  through  sickness  and  non-industrial 
accident  was  about  six  days  for  cases  of  such  disability  lasting  eight 
days  or  more — cases  lasting  more  than  189  days  being  counted  as  189 
day  cases. 

The  problem  of  adjusting  the  result  obtained  through  the  study  of 
these  selected  benefit  associations  to  a  state  health  insurance  system 
must  now  be  considered.  The  condition  that  would  obtain  in  a  state 
health  insurance  system  would  differ,  very  probably,  from  those  that 
obtain  in  the  associations  considered.  Some  of  the  important  differences 
that  would  likely  occur  may  be  stated  as  follows : 

I.  A  less  favorably  selected  body  of  risks  for  any  given  age; 
II.  A  larger  percentage  of  risks  of  advanced  age; 

III.  A  larger  percentage  of  female  members; 

IV.  A  tendency  to  administer  the  funds  in  a  more  liberal  manner. 
All  of  these  would  have  the  effect  of  increasing  the  sickness  rate. 

Just  what  change  in  this  rate  would  be  produced  by  each  of  the  stated 
differences  and  by  any  others  that  might  be  stated,  it  is  impossible  to 
determine  with  accuracy.  Further,  it  is  highly  probable  that  competent 
dctuaries  would  differ  in  their  estimates  of  the  total  effect.  It  is  our 
judgment  that  a  25  per  cent  increase  should  be  allowed  to  make  the 
sickness  rate  arrived  at  in  the  study  of  benefit  associations  applicable  to 
a  state  health  insurance  system.  One  actuary  who  has  been  consulted 
and  who  has  devoted  considerable  attention  to  problems  of  this  char- 
acter, holds  the  view  that  the  increase  should  be  at  least  25  per  cent  to 
provide  a  proper  safety  factor. 

Applying  a  25  per  cent  increase  7.5  days  is  obtained  as  the  min- 
imum estimate  of  the  sickness  rate,  for  the  occupations  studied  in  Part 
I,  applicable  to  a  state  system  of  health  insurance  paying  benefits  for  a 
period  not  to  exceed  twenty-six  weeks  after  a  waiting  period  of  one 
week.  A  25  per  cent  increase  in  the  number  of  compensated  days  yields 
6.0  days  as  the  minimum  number  which  would  be  compensated  in  an 
obligatory  system  paying  benefits  for  twenty-six  weeks  after  the  expir- 
ation of  the  first  seven  days  of  disability. 


335 


PART  II.  A  STUDY  OF  THE  DISABILITY  DATA  FROM  THE 
WORKMEX^S  SICK  AND  DEATH  BENEFIT  FUND  FOR 
THE  YEARS  1912-1916. 

TABLE  I — NUMBER  OF  CASES  OF  DISABILITY,  BY  DURATION  IN  DAYS 
AND  BY  OCCUPATION.  WORKMEN'S  SICK  AND  DEATH  BENEFIT 
FUND,  1912-1916. 


Number  of  cases. 

Duration  in  days. 

Barbers. 

Bar- 
tenders. 

Brick- 
layers 
and 
masons. 

Car- 
penters. 

Painters. 

Plast- 
erers. 

Plumb- 
ers and 
steam- 
fitters. 

Sheet 

metal 

workers. 

1 

4 
10 
18 
12 
8 
5 
21 
9 
11 
8 
3 
2 
6 
5 
3 
2 
5 
3 
1 
0 
2 
2 
1 
0 
3 
3 
6 
13 
12 
8 
7 
3 
4 
5 
2 
2 
1 
1 
4 
1 
2 
1 
1 
1 
0 
0 
7 
0 
0 

4 

9 

11 

19 

12 

11 

31 

12 

14 

9 

10 

15 

6 

16 

10 

2 

8 

8 

8 

2 

12 

4 

2 

11 

4 

6 

1 

24 

28 

11 

16 

7 

4 

3 

8 

4 

8 

2 

3 

5 

1 

2 

1 

6 

5 

2 

1 

1 

6 

3 

15 

10 

20 

25 

23 

35 

13 

27 

19 

16 

21 

7 

22 

9 

14 

11 

10 

10 

4 

19 

6 

9 

9 

10 

3 

8 

27 

23 

14 

18 

16 

11 

6 

2 

3 

2 

3 

3 

2 

2 

1 

2 

7 

3 

6 

2 

2 

6 

13 

54 

81 

118 

122 

90 

25 

94 

111 

73 

85 

71 

53 

137 

61 

49 

52 

50 

43 

34 

85 

31 

36 

40 

22 

28 

23 

163 

139 

97 

89 

63 

54 

39 

30 

21 

14 

28 

16 

16 

7 

8 

5 

41 

27 

20 

14 

8 

13 

7 

14 

42 

38 

42 

25 

86 

28 

32 

25 

21 

29 

13 

36 

18 

24 

16 

11 

14 

6 

24 

12 

9 

14 

15 

12 

11 

55 

50 

38 

15 

24 

16 

13 

7 

13 

6 

3 

5 

4 

4 

2 

2 

15 

14 

3 

7 

2 

4 

2 
3 
3 
9 
6 
5 
10 
3 
0 
3 
4 
0 
3 
8 
2 
3 

\ 

2 
2 
2 
0 
0 
1 
0 
0 
0 
8 
5 
2 
2 
0 
4 
1 
1 
2 
0 
1 
0 
1 
0 
0 

1 

2 
2 
0 

1 
1 
1 

3 

5 

24 

20 

22 

16 

32 

9 

18 

12 

9 

8 

6 

11 

3 

7 

7 

6 

5 

7 

4 

3 

5 

1 

2 

3 

2 

13 

15 

8 

5 

7 

6 

3 

2 

1 

1 

4 

1 

1 

2 

0 

0 

1 

1 

2 

2 

1 

0 

5 

2 

16 

3 

19 

4 

23 

5 

21 

6 

23 

7 

45 

8 

22 

9 

19 

10 

20 

11 

20 

12 

20 

13 

12 

14 

18 

15 

10 

16 

4 

17 

10 

18 

11 

19 

7 

20 

4 

21 

13 

22 

8 

23 

5 

24 

3 

25 

3 

26 

8 

27 

7 

28-34 

25 

35-41 

19 

42-48 

19 

49-  55 

11 

56-62 

7 

63-69 

10 

70-76 

6 

77-83 

3 

84-90 

5 

91-  97 

6 

98-104 

4 

105-111 

0 

112-118 

2 

119-125 

0 

126-132 

3 

133-139 

3 

6 

175-209 

5 

210-244 

1 

245-279 

1 

280-314 

1 

315-364 

1 

Number  of 
cases 

Number  of  mem- 
bers   

228 
1,242 

404 
2,290 

539 
2,241 

2,748 
11,586 

926 
4,389 

109 
558 

326 

1,448 

514 
2,343 

336 


TABLE  I — Continued. 


Number  of  cases. 

Duration  in  days. 

Other 
building 
construc- 
tion. 

Cooks 

and 

waiters. 

Engineers 

and 
firemen. 

Farmers, 
garden- 
ers and 
florists. 

Freight 
handlers. 

Laborers. 

Auto- 
mobile, 
etc., 
manu- 
factur- 
ing. 

Clay 
products. 

1 

1 
5 
5 
5 
5 
5 
16 
0 
4 
6 
3 
2 
7 
4 
0 
4 
1 
2 
1 
2 
3 
0 
2 
1 
2 
0 
0 
5 
5 
4 
2 
3 
0 
2 
3 
0 
1 
1 
0 
0 

1 

0 
2 
2 
2 

1 
0 
1 

1 

6 

13 

12 

18 

20 

16 

42 

15 

20 

12 

17 

15 

13 

20 

11 

7 

7 

13 

5 

7 

10 

6 

7 

4 

3 

9 

4 

29 

15 

14 

13 

15 

9 

11 

6 

4 

3 

1 

4 

2 

4 

2 

1 

4 

6 

2 

1 

0 

6 

4 

10 

32 

30 

42 

29 

76 

31 

28 

21 

24 

25 

19 

34 

15 

9 

16 

18 

13 

8 

14 

8 

12 

6 

10 

11 

8 

34 

36 

17 

21 

15 

9 

9 

10 

8 

5 

9 

4 

5 

5 

1 

4 

8 

4 

1 

4 

2 

2 

2 
3 
7 
7 
13 
7 
30 
7 
11 
16 
7 
4 
6 
6 
4 
7 
9 
6 
3 
3 
8 
0 
2 
3 
5 
4 
2 
17 
11 
4 
4 
1 
4 
4 
1 
1 
2 
2 
1 
0 
2 
1 
1 
1 
1 
1 
1 
1 
0 

1 
5 
3 
4 

4 
4 

14 
4 
4 
7 
6 
5 
9 

17 
5 
4 
3 
3 
4 
2 
8 
3 
4 
0 
2 
2 
1 

13 
8 

10 
9 
4 
3 
1 
2 
1 
1 
0 
4 
2 
1 
2 
0 
5 
1 
3 
0 
0 
1 

33 

103 

173 

238 

274 

196 

433 

171 

200 

154 

142 

165 

124 

220 

98 

92 

92 

83 

90 

73 

128 

49 

69 

51 

42 

42 

51 

287 

218 

133 

112 

69 

91 

46 

32 

25 

2.7 
23 
36 
19 
10 
14 
15 
46 
32 
15 
11 
5 
14 

1 
4 
8 
8 
14 
5 
13 
4 
7 
8 
8 
2 
4 
9 
7 
9 
4 
2 
4 
0 
2 
1 
0 
3 
0 
0 
2 
8 
7 
9 
6 
2 
1 
4 
1 
2 
3 
1 
1 
0 
0 
0 
0 
2 
3 
0 
1 
0 
0 

0 

2 

5 

3 

4 

4 

4 

5 

3 

6 

7 

7 

17 

8 

9 

4 
1 

10 

g 

11 

2 

12 

5 

13 

4 

14 

9 

15 

4 

16 

2 

17 

2 

18 

2 

19 

1 

20 

3 

21 

2 

22 

2 

23 

2 

24 

2 

25 

2 

26 

2 

27 

1 

28-34 

12 

35-41 

6 

42-  48 

3 

49-  55 

2 

56-62 

3 

63-69 

1 

70-76 

4 

77-83 

3 

84-90 

0 

91-  97 

3 

98-104 

0 

105-111 

0 

112-118 

1 

119-125 

0 

126-132 

1 

133-139 

2 

140-174 

1 

175-209 

0 

210-244 

0 

245-279 

1 

280-314 

0 

315-364 

1 

Number  of 
cases 

•Number  of  mem- 
bers   

122 

588 

484 
2,339 

766 
3,378 

243 
1,203 

199 
724 

4,866 
17,700 

180 
735 

144 

652 

337 


TABLE  I — Continued. 


Duration  in  days. 


Number  of  cases. 


Clothing 
manufac- 
turing. 


Dyers. 


Elec- 
trical 
workers. 


Food. 


Slaugh- 
tering and 

meat 
packing. 


Glass 
workers. 


Jewelers. 


Tanners. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 !. 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28-34 

35-  41 

42-48 

49-55 

56-62 

63-69 

70-76 

77-83 

84-  90 

91-97 

98-104 

105-111 

112-118 

119-125 

126-132 

133-139 

140-174 

175-209 

210-244 

245-279 

280-314 

315-364 

Number  of 
cases 

Number  of  mem 
bers 


6 

29 

33 

34 

44 

27 

89 

36 

28 

32 

22 

18 

15 

40 

13 

13 

16 

14 

20 

9 

29 

11 

15 

11 

7 

7 

6 

50 

40 

30 

21 

16 

13 

10 

13 

11 

6 

5 

3 

3 

7 

1 

6 

7 

4 

3 

3 

3 

4 


883 
4,847 


0 
1 

5 
11 
7 
5 
20 
11 
4 
3 
5 
4 
2 
6. 
1 
1 
3 
1 
2 
4 
2 
3 
2 
1 
4 
0 
1 
14 
5 
5 
5 
4 
3 
3 
2 
1 
2 
0 
2 
2 
0 
0 
0 
2 
2 
0 
1 
1 
1 


164 


748 


2 
7 
9 

11 

13 
4 

24 
8 

16 
9 
3 

12 
4 
8 
6 
2 
4 
4 
1 
3 
2 
4 
3 
1 
0 
0 
3 

10 
9 
6 
5 
4 
2 
3 
4 
3 
0 
1 
4 
0 
0 
0 
0 
0 
1 
0 
0 
0 
0 


215 

988 


10 
28 
52 
51 
78 
63 
143 
54 
46 
52 
40 
44 
24 
80 
35 
30 
25 
27 
23 
23 
40 
18 
22 
21 
20 
22 
16 
96 
54 
58 
37 
37 
22 
12 
18 
14 
12 
16 
5 
9 
5 
2 
11 
19 
12 
4 
10 
5 
5 


1,540 
7,507 


7 
28 
52 
58 
63 
40 
111 
38 
47 
45 
40 
32 
38 
66 
31 
23 
23 
35 
27 
16 
31 
14 
18 
12 
7 
12 
19 
99 
55 
43 
43 
31 
25 
21 
8 
10 
6 
10 
6 
10 
3 
4 
3 

10 
12 
4 
5 
4 
6 


1,351 
5,724 


0 

0 

1 

1 

5 

10 

8 

8 

17 

11 

15 

16 

9 

9 

16 

12 

7 

17 

19 

19 

40 

9 

3 

9 

10 

3 

15 

13 

4 

5 

11 

5 

15 

3 

4 

13 

5 

2 

14 

8 

6 

17 

3 

2 

4 

4 

2 

8 

3 

2 

9 

2 

5 

5 

4 

2 

5 

4 

3 

4 

6 

4 

8 

1 

1 

5 

3 

5 

4 

5 

3 

4 

3 

0 

6 

1 

1 

1 

2 

1 

6 

6 

5 

16 

16 

12 

13 

5 

6 

12 

6 

3 

5 

9 

1 

3 

3 

3 

6 

0 

4 

4 

0 

1 

2 

1 

2 

3 

1 

0 

2 

2 

1 

3 

2 

1 

3 

1 

0 

2 

1 

0 

3 

0 

1 

0 

0 

0 

2 

5 

0 

8 

0 

4 

4 

0 

0 

3 

1 

1 

0 

1 

0 

0 

2 

0 

2 

22 

166 

370 

55 

1,169 

1,466 

—22  H  1 


338 


TABLE  I — Continued. 


Ntunber  of  cases. 

- 

Duration  in  days. 

1 

Leather 
workers. 

Liquor 
manu- 
facturing. 

Black- 
smiths. 

Machin- 
ists. 

Holders. 

Other 

metal 

workers. 

Printers. 

Stone 
cutters. 

1 

6 

27 

39 

47 

51 

35 

89 

26 

38 

31 

25 

22 

15 

35 

20 

20 

15 

16 

6 

13 

26 

12 

13 

10 

10 

12 

6 

45 

36 

36 

28 

21 

16 

9 

10 

5 

8 

4 

1 

5 

5 

3 

1 

13 
10 
5 
6 
3 
7 

21 

102 

129 

157 

165 

144 

381 

140 

159 

113 

115 

113 

93 

186 

82 

92 

69 

63 

66 

53 

113 

47 

42 

45 

60 

47 

42 

262 

181 

147 

100 

78 

60 

40 

58 

22 

26 

28 

17 

17 

18 

14 

7 

43 

30 

21 

9 

7 

14 

3 

9 

13 

26 

14 

16 

41 

20 

16 

16 

15 

21 

20 

22 

10 

6 

5 

9 

16 

11 

11 

9 

8 

7 

9 

5 

4 

25 

21 

27 

19 

11 

6 

6 

4 

2 

4 

4 

2 

2 

2 

5 

0 

4 

2 

5 

0 

2 

3 

23 

121 

170 

176 

182 

117 

321 

162 

137 

103 

94 

112 

78 

163 

67 

61 

77 

56 

62 

38 

79 

35 

33 

24 

48 

35 

32 

204 

141 

104 

72 

62 

49 

38 

35 

40 

18 

14 

25 

15 

15 

9 

12 

40 

22 

11 

14 

7 

14 

5 

17 

21 

27 

47 

34 

77 

30 

20 

23 

21 

21 

15 

34 

13 

13 

17 

14 

15 

5 

27 

14 

7 

8 

11 

9 

6 

52 

30 

20 

21 

16 

6 

8 

2 

1 

•? 

5 
2 
2 
1 
1 
5 
4 
1 
0 
0 
0 

9 

39 

66 

75 

99 

63 

142 

57 

47 

62 

50 

56 

37 

72 

31 

36 

41 

23 

24 

21 

33 

19 

17 

20 

20 

17 

14 

100 

60 

48 

31 

29 

30 

17 

9 

22 

14 

10 

6 

6 

3 

3 

2 

12 

2 

7 

3 

1 

1 

6 

16 

26 

35 

31 

19 

47 

18 

15 

11 

20 

23 

7 

24 

11 

7 

13 

8 

7 

6 

12 

6 

■   8 

6 

5 

i 

37 

19 

20 

16 

10 

12 

11 

5 

4 

3 

7 

1 

4 

2 

5 

6 

9 

9 

4 

7 

3 

4 

0 

2 

3 

7 
9 

4 

6 

5 

16 

6 

6 

7 

26 

8 

14 

9 

13 

10 

11 

11 

9 

12 

6 

13 

2 

14 

19 

15 

2 

16 

8 

17 

5 

18 

3 

19 

4 

20 

3 

21 

6 

22 

3 

23 

2 

24 

7 

25 

0 

26 

2 

27 

3 

28-  34 

12 

35-41 

19 

2 

49-  55 

5 

56-  62 

3 

63-  69 

5 

70-  76 

6 

77-83 

2 

84-90 

2 

91-97 

2 

98-104 

3 

105-111 

1 

112-118 

2 

119-125 

n 

126-132 

133-139 

140-174 

175-209 

210-244 

245-279 

2 

280-314 

1 

315-364 

3 

Number  of 

Number  of  mem- 
bers   

941 
4,316 

4,038 
14,324 

518 
2,053 

3,564 
16,023 

737 
2,838 

1,606 
6,907 

591 
3,401 

273 
1  172 

339 

TABLE  I — Concluded. 


Duration  in 
days. 


NTimber  of  cases. 

Tex- 
tile 
manu- 
factur- 
ing. 

To- 
bacco. 

Other 
manu- 
factur- 
ing em- 
ployees. 

Miners. 

Profes- 
sional. 

Trade 

and 

clerical. 

Driv- 
ers. 

Rail- 
road 
em- 
ployees. 

Wood 
work- 
ers. 

All 

other 
occu- 
pations. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27.. 

28-  34 

25-41 

42-48 

49-  55 

56-  62 

63-69 

70-  76 

77-  83 

84-90 

91-97 

98-104 

105-111 

112-118 

119-125 

126-132 

133-139 

140-174 

175-209 

210-244 

245-279 

280-314 

315-364 

Number  of 
cases 

Number  of  mem 
bers 


7 

30 

59 

69 

76 

44 

132 

39 

40 

34 

38 

56 

32 

62 

28 

29 

21 

20 

20 

19 

40 

17 

12 

12 

8 

17 

14 

77 

53 

39 

28 

31 

18 

16 

12 

10 

12 

12 

4 

6 

8 

2 

6 

14 

5 

7 

3 

2 

3 


1,343 
7,287 


30 
48 
59 
43 
58 
33 

328 
93 
90 
66 
65 
55 
53 

143 
49 
47 
40 
38 
29 
■  24 
71 
22 
18 
23 
23 
25 
18 

118 

111 
75 
57 
59 
34 
37 
23 
22 
16 
18 
8 
14 
10 
10 
6 
25 
12 
19 
10 
9 
17 


2,301 
8,897 


4 

5 

1 

27 

23 

3 

39 

41 

7 

38 

74 

6 

57 

91 

7 

26 

80 

2 

85 

164 

17 

31 

89 

10 

23 

81 

8 

37 

87 

9 

22 

57 

6 

32 

90 

6 

16 

59 

2 

27 

119 

6 

17 

41 

1 

15 

52 

1 

20 

50 

5 

12 

42 

1 

18 

47 

1 

11 

28 

0 

34 

68 

6 

6 

27 

0 

8 

29 

2 

11 

23 

2 

5 

23 

1 

6 

24 

0 

4 

19 

1 

47 

164 

6 

28 

111 

7 

36 

67 

4 

25 

59 

3 

19 

35 

1 

14 

36 

2 

12 

24 

1 

11 

25 

1 

8 

20 

2 

6 

18 

1 

6 

11 

0 

7 

14 

1 

3 

12 

1 

1 

11 

1 

5 

8 

0 

3 

8 

0 

6 

17 

2 

4 

24 

1 

1 

8 

0 

1 

7 

0 

0 

3 

0 

2 

5 

1 

12 

31 

.62 

47 

51 

23 

87 

48 

38 

29 

28 

28 

20 

31 

21 

18 

11 

15 

11 

8 

23 

7 

5 

12 

9 

14 

5 

56 

39 

27 

19 

12 

17 

5 

12 

6 

3 

8 

6 

6 

5 

4 

3 

10 

7 

3 

5 

4 

4 


876 
4,164 


2,220 
7,068 


146 


1,192 


956 
5.591 


5 

0 

5 

33 

7 

24 

57 

8 

61 

76 

14 

41 

97 

10 

68 

76 

5 

47 

156 

11 

111 

71 

8 

43 

59 

3 

43 

55 

6 

41 

61 

5 

38 

49 

6 

42 

46 

4 

27 

107 

9 

54 

44 

4 

22 

34 

5 

30 

33 

4 

27 

39 

2 

28 

40 

3 

26 

29 

0 

19 

45 

3 

38 

27 

2 

19 

22 

2 

15 

19 

1 

18 

17 

3 

11 

22 

2 

13 

29 

1 

11 

132 

6 

80 

106 

4 

57 

67 

8 

37 

53 

4 

41 

41 

4 

29 

35 

0 

17 

22 

3 

16 

20 

7 

16 

27 

1 

13 

16 

2 

10 

9 

0 

7 

15 

2 

5 

8 

0 

7 

5 

0 

5 

5 

0 

5 

4 

0 

6 

22 

3 

24 

16 

0 

11 

11 

1 

8 

4 

0 

9 

5 

3 

7 

6 

1 

4 

1,977 

177 

1,336 

6,890 

691 

6,093 

13 

66 

85 

107 

97 

90 

179 

86 

64 

72 

60 

61 

50 

88 

43 

45 

29 

33 

36 

35 

51 

27 

28 

15 

20 

26 

16 

125 

86 

60 

43 

41 

34 

23 

23 

15 

10 

14 

9 

5 

8 

7 

6 

24 

20 

10 

12 

8 

4 


2,109 
9,258 


340 


TABLE  II — ^NUMBER  OF  CASES  OF  DISABILITY,  BY  DURATION  IN  DAYS 
AND  BY  AGE.  WORKMEN'S  SICK  AND  DEATH  BENEFIT  FUND,  1912- 
1916. 


Duration  in 
days. 


20 


25 


30 


35 


40 


45 


50 


55 


60 


65 


70 


75 


80 


1.... 
2.... 
3.... 

4 

5.... 

6 

7.... 

8-... 

9.... 

10.... 

11 

12.... 
13.... 

14 

15 

16 

17.... 
18.... 

19 

20 

21 

22.... 

23 

24 

25 

26 

27 

28-  34. 
35-  41. 
42-  48. 
49-  55. 
56-  62. 
63-  69. 
70-  76. 
77-  83. 
84-  90. 
91-  97. 
98-104. 

105-111. 

112-118. 

119-125. 

126-132. 

133-139. 

140-174. 

175-209. 

210-244. 

245-279. 

280-314- 

315-364. 


Number  of 
cases 


Number  of  mem- 
bers  


4 
5 
6 
14 
16 
8 
22 
11 
13 
10 
12 
8 
2 
8 
9 
4 
3 
3 
4 
0 
7 
3 
4 
4 
2 
2 
1 
15 
8 
6 
3 
0 
2 
0 
0 
1 
2 
0 
0 
1 
0 
0 
0 
1 
0 
0 
0 
0 
0 


224 


786 


5 
21 
29 
35 
41 
15 
71 
20 
27 
16 
15 
16 
10 
19 

9 
11 

6 

6 

91 
10 
14 

6 

8 

4 

4 
10 

2 
25 
18 
12 
10 

6 

6 

5 

4 

3 

0 

3 

0 

2 

3 

1 

1 

2 

1 

1 

0 

1 

0 


543 


5 

36 

46 

50 

57 

51 

106 

49 

44 

25 

27 

22 

12 

47 

16 

13 

16 

17 

15 

8 

23 

12 

5 

13 

5 

7 

6 

35 

29 

21 

15 

13 

6 

7 

7 

6 

5 

3 

2 

4 

3 

2 

0 

15 

4 

1 

1 

2 

2 


916 


2,367  3,978 


8 

33 

51 

59 

66 

37 

105 

65 

31 

30 

46 

41 

16 

53 

19 

29 

18 

17 

17 

8 

29 

11 

7 

10 

10 

15 

12 

64 

42 

27 

21 

13 

11 

8 

11 

10 

6 

6 

9 

3 

2 

0 

2 

5 

4 

4 

3 

2 

5 


1,101 


5,043 


8 

44 

57 

74 

73 

38 

138 

47 

43 

50 

36 

53 

30 

59 

31 

24 

23 

19 

23 

16 

29 

17 

10 

11 

15 

17 

16 

85 

39 

49 

30 

32 

21 

18 

10 

9 

7 

2 

9 

7 

5 

4 

5 

9 

8 

4 

3 

5 

5 


1,367 


6,144 


6 

29 

47 

59 

59 

48 

149 

53 

43 

43 

37 

45 

34 

73 

31 

29 

31 

27 

20 

29 

28 

12 

21 

10 

15 

18 

20 

79 

68 

39 

42 

23 

26 

14 

13 

16 

5 

9 

15 

5 

3 

3 

4 

14 

5 

5 

5 

3 

2 


1,414 


6,404 


4 

22 

34 

54 

55 

46 

114 

35 

44 

38 

40 

41 

40 

64 

34 

24 

23 

24 

14 

25 

36 

12 

23 

19 

16 

15 

11 

86 

64 

48 

42 

21 

27 

14 

16 

11 

9 

5 

7 

9 

6 

4 

3 

19 

13 

6 

5 

5 

3 


1,330 


5,789 


4 

12 

21 

26 

31 

34 

89 

30 

36 

33 

18 

25 

27 

50 

24 

16 

13 

16 

18 

18 

32 

9 

5 

15 

18 

9 

10 

64 

51 

44 

30 

32 

27 

13 

18 

12 

4 

9 

3 

10 

6 

3 

4 

18 

19 

5 

3 

4 

8 


1,026 


1 
3 

9 

14 

8 

11 

42 

22 

10 

15 

14 

15 

9 

13 

5 

6 

8 

13 

9 

4 

17 

4 

9 

5 

4 

4 

6 

35 

25 

24 

13 

12 

13 

9 

5 

4 

6 

7 

6 

6 

4 

1 

1 

13 
7 
5 
4 
2 
7 


489 


4,200  1,982 

I 


1 
1 

6 
4 
5 
3 
13 
6 
1 
3 
2 
4 
8 
7 
1 
3 
2 
3 
1 
2 
6 
3 
2 
1 
1 
1 
1 
13 
14 
11 
6 
6 
7 
2 
1 
4 
2 
4 
0 
2 
2 
1 
2 
3 
2 
1 
0 
1 


177 


661 


0 

0 

0 

0 

1 

1 

1 

2 

0 

2 

0 

0 

1 

2 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

1 

0 

0 

1 

0 

3 

1 

0 

0 

0 

0 

0 

0 

0 

0 

1 

1 

0 

1 


21 

70 


0 
0 
0 
0 
0 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

1 

0 

1 

0 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 


5 

18 


0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

1 

0 


341 


TABLE  II — Concluded. 


Duration  in 
days. 


Un- 

der 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

65-69 

VO- 

Vb- 

20. 

79 

AU 
ages. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28-  34 

35-41 

42-  48 

49-55 

56-62 , 

63-  69 

70-76 

77-83 

84-  90 

91-  97 

98-104 

105-111 

112-118 

119-125 

126-132 

133-139 

140-174 

175-209 

210-244 

245-247 

280-314 

315-364 

Number  of 
cases... 

Number  of 
members . . 


1 
6 
9 
10 
14 
0 
11 
8 
6 
3 
5 
6 
0 
8 
4 
2 
1 
2 
0 
0 
4 
1 
0 
2 
0 
2 
0 
9 
3 
2 
2 
3 
0 
1 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 

1 

0 
0 
0 
0 


127 


406 


17 

71 

110 

117 

148 

54 

189 

75 

82 

69 

60 

57 

20 

67 

39 

27 

27 

27 

35 

12 

33 

18 

12 

12 

20 

17 

11 

95 

63 

44 

33 

24 

17 

11 

13 

9 

7 

5 

3 

4 

3 

3 

1 

5 

4 

0 

2 

3 

3! 


35 

136 

196 

212 

254 

113 

391 

162 

164 

115 

121 

117 

57 

158 

60 

73 

69 

53 

41 

32 

84 

33 

41 

36 

32 

30 

22 

163 

130 

82 

72 

58 

38 

23 

19 

13 

12 

19 

8 

6 

10 

7 

4 

21 

19 

12 

11 

5 

5 


1,778  3,574 


7,168  15,267 


51 

45 

40 

169 

167 

185 

281 

254 

254 

266 

325 

313 

312 

338 

358 

197 

222 

237 

516 

618 

648 

213 

250 

252 

200 

232 

280 

152 

225 

222 

148 

195 

206 

157 

187 

251 

81 

142 

149 

224 

262 

314 

85 

129 

152 

74 

145 

124 

106 

119 

123 

82 

107 

122 

86 

101 

135 

43 

71 

89 

121 

139 

191 

61 

55 

80 

44 

65 

86 

50 

68 

80 

42 

60 

69 

47 

63 

82 

27 

51 

76 

245 

348 

425 

167 

274 

296 

125 

145 

226 

90 

141 

151 

55 

115 

124 

53 

80 

104 

39 

51 

88 

29 

43 

71 

25 

39 

53 

20 

34 

43 

17 

35 

36 

15 

32 

45 

9 

28 

28 

15 

13 

29 

11 

16 

18 

8 

17 

15 

38 

42 

72 

24 

32 

59 

12 

26 

30 

13 

20 

25 

6 

8 

17 

11 

23 

31 

4,862 

6,197 

7,104 

21,886 

27,496 

30,746 

30 

132 

215 

257 

279 

269 

649 

238 

229 

227 

209 

208 

174 

335 

138 

165 

150 

149 

110 

112 

194 

93 

100 

63 

81 

80 

76 

448 

338 

254 

195 

148 

106 

83 

84 

66 

47 

50 

43 

27 

23 

30 

18 

74 

47 

34 

27 

22 

24 


7,150 


31,579 


26 

75 

141 

186 

206 

225 

503 

169 

181 

184 

157 

166 

173 

313 

136 

111 

112 

101 

102 

102 

170 

71 

75 

88 

68 

68 

74 

400 

279 

234 

176 

136 

127 

99 

73 

67 

49 

49 

35 

40 

29 

13 

30 

90 

47 

26 

23 

18 

21 


6,044 


25,484 


16 

6 

3 

0 

48 

22 

2 

0 

86 

31 

9 

0 

109 

42 

6 

1 

135 

33 

10 

1 

128 

46 

7 

3 

316 

138 

35 

2 

135 

62 

12 

3 

141 

41 

14 

0 

114 

47 

10 

2 

90 

44 

10 

1 

96 

61 

12 

0 

112 

48 

13 

2 

218 

73 

27 

4 

88 

21 

9 

0 

79 

31 

8 

1 

63 

36 

4 

1 

66 

27 

6 

2 

68 

41 

8 

2 

58 

19 

7 

0 

131 

57 

20 

0 

53 

17 

7 

0 

51 

26 

7 

0 

50 

16 

7 

1 

59 

16 

8 

0 

44 

20 

3 

0 

41 

23 

7 

0 

267 

127 

45 

3 

230 

94 

33 

2 

163 

78 

23 

3 

135 

54 

28 

4 

99 

50 

22 

0 

87 

64 

19 

0 

64 

35 

13 

1 

60 

29 

10 

1 

54 

17 

11 

5 

36 

19 

12 

3 

31 

29 

11 

1 

35 

20 

1 

0 

40 

15 

6 

0 

21 

13 

5 

0 

19 

13 

3 

0 

21 

13 

6 

1 

75 

45 

13 

0 

54 

27 

6 

0 

27 

23 

6 

1 

22 

21 

2 

1 

11 

8 

5 

0 

22 

21 

6 

1 

4,168 

1,859 

557 

53 

16,229 

6,686 

1,843 

170 

10 

49 


271 

1,014 

1,587 

1,846 

2,089 

1,503 

4,017 

1,580 

1,570 

1,371 

1,247 

1,318 

971 

2,005 

862 

841 

811 

745 

729 

546 

1,144 

490 

508 

473 

455 

456 

408 

2,576 

1,910 

1,381 

1,081 

836 

695 

508 

433 

359 

283 

283 

237 

203 

161 

133 

134 

476 

320 

197 

167 

104 

168 


43,502 
185, 167 


343 

TABLE  III— DISTRIBUTION  OP  10,000  CASES  OF  DISABILITY  LASTING 
SEVEN  DAYS  OR  MORE  BY  DURATION  IN  DAYS  FOR  SELECTED  AGE 
GROUPS. 


Duration  in  days. 

Case  distribution  per  10,000  cases  lasting  seven 
days  or  more. 

20-24 

25-29 

30-34 

35-59 

40-44 

1-6             

4,100 

4,377 

1,856 

975 

753 

500 

349 

261 

190 

135 

87 

103 

71 

66 

40 

24 

32 

24 

24 

8 

40 

31 

0 

16 

24 

24 

3,600 

4,288 

1,849 

1,058 

620 

495 

312 

274 

221 

145 

88 

72 

49 

46 

72 

30 

23 

38 

27 

15 

80 

72 

46 

42 

19 

19 

3,558 

4,091 

1,952 

1,093 

683 

466 

349 

251 

153 

148 

109 

81 

70 

56 

47 

42 

25 

41 

31 

22 

106 

67 

33 

36 

17 

31 

2,788 

3,816 

1,927 

1,034 

718 

565 

299 

291 

237 

165 

105 

89 

80 

71 

72 

66 

58 

27 

33 

35 

87 

66 

54 

41 

17 

47 

2,426 

7-  13 

3,512 

14-20 

1,852 

21-27 

1,161 

28-34   

743 

35-41 

518 

42-  48   

396 

49-  55 

264 

56-62 

217 

63-  69       

182 

70-  76 

154 

77-83 

124 

84-  90 

93 

91-97 

75 

98-104 

63 

105-111 

79 

112-118 

49 

119-125 

51 

1 26-1 32 

31 

133-139 

27 

140-174 

126 

103 

210-244 

52 

245-279 

44 

280-31 4 

30 

54 

10,000 

10,000 

10,000 

10,000 

10,000 

TABLE  III — Concluded, 


Duration  in  days. 


Case  distribution 

per  10,000 

cases  lasting  seven 

Case  distri- 

days or  more. 

bution  per 

100,000 

cases  lasting 

seven  days 

45-49 

50-54 

55-59 

60-64 

65-69 

or  more, 
all  ages. 

1,981 

1,657 

1,432 

1,072 

712 

23,613 

3,241 

2,957 

2,754 

2,627 

2,038 

34,309 

1,942 

1,884 

1,755 

1,477 

1,327 

18,581 

1,151 

1,184 

1,177 

1,042 

1,135 

11,179 

751 

771 

732 

756 

866 

7,320 

566 

538 

631 

560 

635 

5,427 

426 

451 

447 

465 

442 

3,924 

327 

339 

370 

322 

538 

3,072 

247 

262 

271 

298 

423 

2,376 

178 

245 

239 

381 

365 

1,975 

139 

191 

176 

208 

250 

1,443 

141 

141 

165 

173 

193 

1,230 

111 

129 

148 

101 

212 

1,020 

79 

95 

99 

113 

231 

804 

84 

94 

85 

173 

212 

804 

72 

68 

96 

119 

19 

673 

,    45 

77 

109 

89 

115 

577 

39 

56 

58 

78 

97 

457 

50 

25 

52 

77 

58 

378 

30 

58 

58 

77 

115 

381 

124 

174 

206 

268 

250 

1,353 

79 

91 

148 

161 

115 

909 

56 

50 

74 

137 

115 

560 

45 

44 

60 

125 

38 

475 

37 

35 

30 

48 

96 

296 

40 

41 

60 

125 

115 

477 

10,000 

10,000 

10,000 

10,000 

10,000 

10,000 

1-  6.. 
7-  13.. 

14-  20.. 

21-  27.. 

28-  34.. 

35-  41 . . 

42-  48. . 

49-  55. . 

56-  62.. 

63-  69.. 

70-  76. . 

77-  83.. 

84-90.. 

91-  97.. 

98-104.., 
105-111... 
112-118... 
119-125... 
126-132... 
133-139... 
140-174... 
17.5-209... 
210-244... 
245-279... 
280-314... 
315-364... 

Total 


343 


TABLE  IV— DISTRIBUTION  PER  100,000  CASES,  OF  CASES  OP  DISABILITY, 
DAYS  OF  DISABILITY,  AND  ACCUMULATED  DAYS  OF  DISABILITY.  BY 
DURATION  IN  DAYS. 


juration  in  days. 


Number 
of  cases. 


Case  dis- 
tribution 
per  100,000 
cases. 


Davs  of 
disaDility 
per  100,000 

cases. 


Accumu- 
lated days 
of  disability 
per  100,000 
cases. 


1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18- 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 


28-  34. 

35-  41. 

42-  48. 

49-  55. 

56-  62. 

63-69. 

70-76. 

77-  83. 

84-  90. 

91-  97. 

98-104. 
105-111. 
112-118. 
119-125. 
126-132. 
133-139. 
140-174. 
175-209. 
210-244. 
245-279. 
280-314. 
315-364. 


Total . 


271 

1,014 

1,587 

1,846 

2,089 

1,503 

4,017 

1,580 

1,570 

1,371 

1,247 

1,318 

971 

2,005 

862 

841 

811 

745 

729 

546 

1,144 

490 

508 

473 

455 

456 

408 

2,576 

1,910 

1,381 

1,081 

836 

695 

508 

433 

359 

283 

283 

237 

203 

161 

133 

134 

476 

320 

197 

167 

104 

168 

43,502 


623 

2,330 

3,648 

4,243 

4,802 

3,455 

9,234 

3,632 

3,609 

3,152 

2,867 

3,030 

2,231 

4,609 

1,982 

1,933 

1,864 

1,713 

1,676 

1,255 

2,630 

1,126 

1,168 

1,087 

1,046 

1,047 

938 

5,922 

4,391 

3,175 

2,485 

1,922 

1,598 

1,168 

995 

825 

651 

651 

545 

467 

370 

306 

308 

1,094 

736 

453 

383 

239 

386 

100,000 


623 

4,660 

10,944 

16,972 

24,010 

20,730 

64,638 

29,056 

32,481 

31,520 

31,537 

36,360 

36,389 

64,526 

29,730 

30,928 

31,688 

30,834 

31,844 

25,100 

55,230 

24,772 

26,864 

26,088 

26, 150 

27,222 

25,326 

183,582 

166,858 

142,875 

129,220 

113,398 

105, 468 

85,264 

79,600 

71,775 

61, 194 

65,751 

58,860 

53,705 

45, 140 

39,474 

41,888 

171,758 

141,312 

102,  ,S.U 

100,346 

70,983 

131,240 

2,958,744 


623 

5,283 

16,227 

33,199 

57,209 

77,939 

142, 577 

171,633 

204, 114 

235,634 

267, 171 

303, 531 

339, 920 

404,446 

434, 176 

465, 104 

496,792 

527,626 

559,470 

584, 570 

639,800 

664,572 

691,436 

717,524 

743,674 

770,896 

796,222 

979,804 

1,146,662 

1,289,537 

1,418,757 

1,532,155 

1,637,623 

1,722,887 

1,802,487 

1,874,262 

1,935,456 

2,001,207 

2,060,067 

2,113,772 

2,158,912 

2,198,386 

2,240,274 

2,412,032 

2,5o3,344 

2,656,175 

2,756,521 

2,827,504 

2,958,744 


344 


TABLE    V— AVERAGE    DURATION    OP    DISABILITY    PER    CASE    AND    PER 

MEMBER    BY     OCCUPATION. 

(These  figures  are  based  on  cases  lasting  eight  days  or  more;   cases  lasting  more 

than  189  are  counted  as  189  day  cases.) 


Occupation. 


Number 
of  cases. 


Number  of     Number 

members.     2-^t7A°^ 
disability. 


Average 
compen- 
sated days 

of  dis- 
ability per 
member. 


Average  duration 
in  days. 


Per  case. 


Per 
member. 


Barbers 

Bartenders 

Bricklayers  and  masons 

Carpenters 

Painters 

Plasterers 

Plumbers 

Sheet  metal  workers 

Building  and  construction 

Cooks  and  waiters 

Engineers  and  firemen 

Farmers,  gardeners  and  florists. 

Freight  handlers 

Laborers 

Auto,  etc.,  manufacturing 

Clay  products 

Clothing  manufacturers 

Dyers 

Electrical  workers 

Food 

Slaughtering  and  meat  packing 

Glass  workers 

Jewelers 

Tanners 

Leather  works 

Liquor  manufacturers 

Blacksmiths 

Machinists 

Molders 

Meial  workers 

Printers 

Stone  cutters 

Textile  manufacturers 

Tobacco 

Manufacturing  employees 

Miners 

Professional 

Trade  and  clerical 

Drivers 

Railroad  employees 

Wood  workers 

All  others* 

Total 


150 
307 
408 

2,245 
672 
71 
204 
362 
80 
357 
543 
174 
164 

3,416 
127 
104 
621 
115 
145 

1,115 
992 
162 
103 
253 
647 

2,939 
396 

2,454 
509 

1,113 
411 
203 
926 

1,702 
600 

1,742 
103 
643 

1,477 
122 
979 

1,472 


31, 328 


2,290 

2,241 

11,586 

4,389 

558 
1,448 
2,343 

588 
2,339 
3,378 
1,203 

724 
17,700 

735 

652 
4,847 

748 

988 
7,507 
5,724 

955 
1,169 
1,466 
4,316 
14,324 
2,053 
16,023 
2,838 
6,907 
3,401 
1,172 
7,287 
8,897 
4,164 
7,068 
1,192 
5,591 
6,890 

691 
6,093 
9,258 


184,985 


6,569 

13,629 

16,036 

83,829 

27,897 

3,352 

6,992 

13,050 

3,693 

14,375 

20,293 

5,753 

6,676 

117,053 

4,598 

3,878 

23,418 

4,786 

4,353 

42,906 

36,676 

5,907 

4,046 

10, 113 

26,537 

107,591 

14,468 

89,483 

15,840 

36,471 

19,490 

8,295 

33,648 

66,885 

21, 160 

61,870 

3,349 

24,504 

55,366 

4,921 

39,746 

55,491 


.1,164,993 


4.4 

43.8 

5.1 

44.4 

5.9 

39.3 

5.9 

37.3 

5.3 

41.5 

5.1 

47  2 

3.8 

34  3 

4.5 

36.0 

5.3 

46.2 

5.1 

40.3 

4.9 

37.4 

3.8 

33.1 

7.6 

40.9 

5.3 

34.3 

5.0 

36.2 

4.8 

37.3 

3.9 

37.7 

5.3 

41.6 

3.4 

30.0 

4.7 

38.5 

5.2 

37.0 

5.0 

36.5 

2.8 

39.3 

5.7 

40.0 

5.1 

41.0 

6.1 

36.6 

5.6 

36.5 

4.5 

36.5 

4.3 

31.1 

4.2 

32.8 

4.9 

47.4 

5.9 

40.9 

3.7 

36.3 

6.2 

39.3 

4.1 

35.3 

7.0 

35.5 

2.2 

32.5 

3.6 

38.1 

6.5 

37.5 

5.9 

40.3 

5.4 

40.6 

4.9 

37.7 

5.1 

37.2 

5.3 
6.0 


6.0 
4.8 
5.6 
6.3 
6.1 
6.0 
4.8 
9.2 
6.6 
6.3 


6.2 
3.5 
6.9 


8.8- 

2.8 

4.4 

8.0 

7.1 

6.5 

6.0 


6.3 


*  More  than  80  occupations  are  included  under  this  heading. 


345 


TABLE    VI — AVERAGE    DURATION    OF    DISABILITY    PER    CASE    AND    PER 

MEMBER,   BY  AGE  GROUPS. 

(These  figures  are  based  on  cases  lasting-  eight  days  or  more  ;   cases  lasting  more 

than  189  days  are  counted  as  189  day  cases.) 


Age. 


Number 
of  cases. 


Number  of 
members. 


Number 
of  days  of 
disability. 


Average 
compen- 
sated days 

of  dis- 
ability per 
member. 


Average  duration 
in  days. 


Per  case. 


Per 

member. 


Under  20 . . 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

65-69 

70-74 

75-79 

80  and  over 

Total.. 


76 

1,072 

2,237 

3,070 

4,228 

5,069 

5,319 

4,682 

3,330 

1,541 

485 

46 

9 

2 


31,170 


406 

7,168 

15,267 

21,886 

27,496 

30, 746 

31,579 

._25,484 

16,229 

6,686 

1,843 

170 

49 

6 


185,011 


1,855 

30,406 

69,720 

97,345 

143,710 

185,596 

197,827 

185,852 

144,666 

78,234 

25,221 

2,454 

443 

227 


1,163,556 


3.3 
3.2 
3.5 
3.5 
4.2 
4,9 
5.1 
6.0 


7.5 
10.1 
11.8 
12.5 

7.8 
35.5 


5.1 


24.4 
28.4 
31.2 
31.7 
34.0 
36.6 
37.2 
39.7 
43.4 
50.8 
52.0 
53.3 
49.2 
113.5 


37.3 


4.6 

4.2 

4.6 

4.4 

5.2 

6.0 

6.3 

7.3 

8.9- 

11.7 

13.7 

14.4 

9.0 

37.8 


6.3 


346 

TABLE   VII — AVERAGE   DURATION    OF   DISABILITY    PER    CASE    AND   PER 

MEMBER  BY  SELECTED  AGES. 

(These  figures  are  based  on  cases  lasting  eight  days  or  more  ;   cases  lasting  more 

than  189  days  are  counted  as  189  day  cases.) 


Number 
of  cases. 

Number  of 
members. 

Number 
of  days  of 
disability. 

Average 
compen- 
sated days 

of  dis- 
ability per 
member. 

Average  duration 
in  days. 

Age. 

Per  case. 

Per 

member. 

20 

149 

326 

565 

742 

935 

1,017 

1,001 

809 

401 

144 

18 

4 

786 
2,367 
3,978 
5,043 
6,144 
6,404 
5,789 
4,200 
1,982 

661 
70 
18 

3,405 

9,585 

18,502 

29,402 

32, 738 

35,680 

39,154 

35,578 

19,849 

7,107 

1,186 

119 

3.0 
3.1 
3.7 
4.8 
4.3 
4.5 
5.6 
7.1 
8.6 
9.1 
15.1 
5.1 

22.9 
29.4 
32.6 
39.6 
35.0 
35.1 
39.1 
44.0 
49.5 
49.4 
65.9 
29.8 

4.3 

25 

4.0 

30 

4.7 

35 

5.8 

40 

5.3 

45 

5.6 

50 

6.8 

55 

8.5 

60 

10.0 

65 

10.8 

70 

16.9 

75 

6.6 

Total 

6,111 

37,442 

232,305 

5.1 

38.0 

6.2 

347 


SPECIAL  REPORT  III.     DISPENSARIES  AND  CLINICS  IN 

ILLINOIS. 


[Note  by  the  Secretary. — Because  of  the  importance  of  the  public  dispensary  in 
meeting  the  needs  of  the  sick  poor  and  because  of  tlie  question  of  abuse  frequently- 
raised  in  connection  with  the  admission  of  patients,  the  Commission  planned  to 
make  an  inclusive  investigation  of  the  dispensaries  in  the  State.  Mr.  Harold  Fish- 
bein  was  assigned  to  this  special  investigation.  Before  his  report  was  completed, 
however,  he  was  accepted  for  military  service.  His  data  have  been  presented  in 
summary  form  by  Mr.  Ransom,  a  member  of  the  Commission.] 

Medical  charity  in  most  communities  of  considerable  size  may  be 
afforded  in  one  or  more  of  several  ways.  Most  doctors  have  private 
patients  who  are  unable  to  pay  for  the  service  rendered  them  and  con- 
sequently receive  it  gratuitously.  Counties,  townships  or  municipalities 
may  employ  physicians  to  give  medical  service  to  indigent  persons  in 
their  own  homes.  Hospitals  both  public  and  private  furnish  free  service 
to  the  poor.  Dispensaries  and  clinics  provide  medical  treatment  for 
large  numbers  of  poor  people. 

Because  of  the  importance  of  dispensaries  and  clinics  and  the  ques- 
tions raised  as  to  the  place  they  should  occupy  in  the  provision  for 
medical  care,  the  Commission  has  sought  to  investigate  them  as 
thoroughly  as  possible.  As  com^plete  data  as  could  be  obtained  with  the 
conditions  under  which  the  investigation  was  made  were  secured  from 
these  institutions. 

The  Dispensary  investigation  did  not,  however,  cover  certain  types 
of  institutions.  Those  excluded  were  (a)  dispensaries  operated  by 
city  and  county  physicians,  (b)  clinics  affiliated  with  the  Schools  of 
Chiropody,  of  which  there  are  three  in  Chicago,  (c)  Infant  Welfare 
stations  of  which  there  are  many  in  Chicago  and  a  smaller  number  in 
other  cities  of  the  State,  (d)  hospital  out-patient  departments  main- 
tained by  corporations  for  the  treatment  of  employees,  and  (e)  out- 
patient departments  of  the  U.  S.  Marine  Hospitals  at  Cairo  and  Chicago 
maintained  for  the  treatment  of  members  of  the  Merchant  Marine. 

In  Chicago  all  dispensaries  are  operated  subject  to  control  by  the 
Department  of  Health  under  a  city  ordinance.  Hence,  it  was  possible 
to  easily  obtain  a  list  of  all  Chicago  dispensaries.  Elsewhere  in  the 
State  no  official  lists  of  such  institutions  were  available,  but  by  use  of 
directories  and  with  the  help  of  hospitals  and  public  health  authorities 
practically  all  of  the  dispensaries  in  the  State  were  located.  Ninety- 
eight  dispensaries  and  clinics  of  the  various  types  were  located  and 
studied.  Nine  others  had  ceased  operation  during  the  last  year  be- 
cause of  the  enlistment  of  many  of  their  staff  members  in  the  Medical 
Corps  of  the  Army  and  Navy.' 

Location  and  classification. — Of  the  105  dispensaries  studied,  60 
are  in  Chicago  and  45  in  other  parts  of  the  State.     Dispensaries  may  be 


348 

divided  into  two  classes— general  and  special.  A  general  dispensary 
is  one  which  does  not  limit  its  service  either  as  to  class  of  diseases  or 
types  of  patients.  A  special  dispensary  may  treat  only  one  disease- 
as  tuberculosis,  or  one  group  of  patients— as  children,  or  may  use  a 
specialized  form  of  treatment— as  osteopathy.  Special  dispensaries  may 
be  further  classified  as  in  the  table  below,  which  shows  the  location  and 
types  of  dispensaries  included  in  this  investigation. 

CHICAGO. 

1  Q 
General  dispensaries   

Special  dispensaries —  '     „ 

Eye,  ear,  nose  and  throat ^ 

Women  and  children * 

Children    * 

Obstetrics    5 

Venereal  disease ^ 

Osteopathy,   chiropractic,   etc o 

Dental    1 J 

Tuberculosis °          '*-'■ 

60 
ILLINOIS  OUTSIDE  OF  CHICAGO. 

General  dispensaries 8 

Special  dispensaries — 

Tuberculosis 18 

Infantile  paralysis 11 

Other  special  dispensaries 8  37 

45 

Other  factors  than  convenience  to  the  public  have  in  many  ways 
determined  the  location  of  the  dispensary.  Those  connected  with 
medical  schools  have  had  their  location  fixed  by  the  location  of  the 
schools  which  in  turn  are  located  in  relation  to  hospitals.  In  Chicago 
there  are  two  fairly  well  defined  medical  centers,  one  on  the  West  Side 
and  one  on  the  South  Side.  In  these  two  rather  restricted  areas  are 
located  eight  of  the  larger  general  dispensaries  and  two  large  dental 
clinics.  For  the  Municipal  Tuberculosis  Dispensaries  and  school  dental 
clinics  the  city  has  been  divided  into  districts  and  the  dispensaries  located 
so  that  all,  or  nearly  all  parts  of  the  city  are  served.  The  location  of 
other  dispensaries  has  been  determined  by  that  of  the  hospitals,  churches, 
social  settlements,  etc.  The  result  is  that  there  are  large  areas  in 
Chicago  in  which  the  population  has  no  ready  access  to  dispensaries, 
while  in  other  areas  patients  may  choose  among  several  such  institutions 
which  are  conveniently  accessible. 

Support  and  control. — As  to  their  support  and  control  dispensaries 
may  be  classed  as  public  and  private.  Most  of  the  tuberculosis  dis- 
pensaries are  supported  out  of  public  funds.  The  same  is  true  of  in- 
fantile paralysis  clinics,  school  dental  clinics  and  a  few  others.  In 
some  public  dispensaries  patients  who  are  able  to  do  so  pay  fees,  the 
money  thus  obtained  going  to  augment  the  public  appropriation  for  the 
support  of  these  institutions.  Private  dispensaries  are  controlled  by 
private  corporations  or  organizations.  Their  support  may  come  from 
one  or  more  of  several  sources.  Those  connected  with  medical  and 
dental  schools  may  be  supported  in  part  by  the  schools.  Out-patient 
departments  of  hospitals  are  supported  out  of  the  same  funds  as  are  the 
other   departments   in   the   hospitals   with   which   they   are   connected. 


349 

-Other  dispensaries  may  be  supported  privately  as  charitable  institutions 
by  people  interested  in  this  form  of  philanthropy.  In  many  dispensaries 
patients  pay  small  fees  which  go  to  the  support  of  these  institutions. 
Insufficient  and  uncertain  financial  support  has  been  a  potent  factor  in 
checking  the  development  of  dispensaries.  There  is  frequently  in- 
adequate service  because  the  money  is  lacking  to  properly  construct, 
equip,  administer  and  man  these  institutions.  Dispensaries  in  Chicago 
are  subject  to  certain  supervision  and  control  by  the  Department  of 
Health  under  a  city  ordinance.  This  ordinance  makes  certain  speci- 
fications as  to  sanitary  conditions,  records,  isolation  of  contagious  cases, 
reporting  of  cases  of  reportable  diseases,  etc.  All  dispensaries  in  the 
city  are  subject  to  inspection  by  the  Department  of  Health  and  must 
pay  an  annual  license  fee  of  twenty  dollars. 

Except  as  indicated  above,  the  Commission's  investigation  em- 
braced every  type  of  dispensary  and  clinic — the  general  and  the  special, 
the  medical  and  the  dental,  the  public  and  the  private.  Questionnaires 
were  sent  to  all  the  dispensaries  located,  with  the  exception  of  the  Chicago 
Tuberculosis  Dispensaries  (information  about  which  was  obtained 
through  the  dispensary  Department  of  the  Municipal  Tuberculosis  Sani- 
tarium for  which  we  are  indebted),  and  the  Infantile  Paralysis  Clinics 
maintained  by  the  Department  of  Public  Health.  Where  schedules  were 
incomplete,  personal  visitations  were  made;  these  visits  also  enabled 
the  Commission  to  obtain  information  not  readily  secured  by  the  ques- 
tionnaire method  such  as  relates  to  how  records  are  kept  and  what  in- 
formation they  contain,  conditions  and  equipment  of  clinics,  methods 
followed  in  administration  and  treatment  and  the  like.  The  "block 
studies"  made  in  Chicago  by  the  Commission  show  something  as  to  the 
extent  to  which  dispensaries  are  used,  the  attitude  of  people  toward  the 
dispensaries  and  extent  of  "dispensary  abuse"  (the  use  of  medical 
service  of  dispensaries  by  those  able  to  pay  for  treatment). 

The  various  types  of  dispensaries  investigated  were  found  to  serve  a 
large  number  of  persons.  The  number  of  visits  made  to  them  by  patients 
during  the  last  year  approximated  860,000.  Of  this  number  835,000 
visits  were  made  to  Chicago  dispensaries.  How  many  different  patients 
were  treated  cannot  be  so  accurately  estimated  because  of  the  system  of 
records  kept.  There  is  a  quite  general  acceptance  among  dispensary 
officials  of  the  estimate  of  an  average  of  four  visits  per  patient.  On  this 
basis  215,000  persons  in  Illinois  sought  treatment  last  year  in  dispen- 
saries. Of  this  number  208,750  visited  Chicago  dispensaries.  Taken 
in  relation  to  population  these  figures  indicate  that  in  the  State  as  a 
whole  seven  out  of  every  200  people  sought  medical  service  in  these 
institutions.     In  Chicago  the  figures  were  17  out  of  every  200. 

What  it  costs  to  serve  these  patients  cannot  be  estimated  with  any 
degree  of  accuracy.  Nine  of  the  dispensaries  with  222,803  visits  and 
with  receipts  from  patients  amounting  to  $55,942,  reported  expenditures 
totaling  $106,389.  The  expenditures  reported  do  not,  however,  in  the 
larger  number  of  cases,  include  sums  spent  for  heat,  light  and  rent, 
which  are  donated  by  the  affiliated  institutions.  In  fact  the  figures 
given  show  little  more  than  a  part  of  the  operating  expenses.     In  this 


350 

connection  it  is  to  be  remembered  also  that  most  of  the  service  of  physi- 
cians is  donated.  The  dispensaries  and  clinics  of  Chicago  exclusive  of 
tuberculosis  and  dental  clinics,  which  are  operated  in  a  different  manner 
and  are  dealt  with  especially  in  this  report,  have  on  their  staffs  742 
physicians  of  whom  only  37  are  paid.  Three  dispensaries  outside  of 
Chicago  reported  47  physicians  on  their  staffs,  all  donating  their  services. 
The  amount  of  time  given  by  the  many  physicians  varies  considerably. 
In  some  cases  it  is  only  one  hour,  in  others  several  hours  per  week. 

Dispensary  administration,  procedure  and  class  of  treatment  differ 
from  one  institution  to  another,  for  there  are  dispensaries  and  dis- 
pensaries; the  good  and  the  bad;  those  operated  at  a  loss  and  those  that 
make  a  profit;  those  which  treat  every  one  irrespective  of  ability  to  pay 
and  those  which  make  close  inquiry  into  financial  status;  those  which 
give  every  form  of  treatment  from  the  removal  of  a  splinter  to  treatment 
by  hydrotherapy;  there  are  institutions  which  use  every  known  thera- 
peutic agency  grading  down  to  those  which  use  a  specialized  form  of 
treatment  as  yet  in  an  experimental  stage.  An  adequate  discussion  of 
the  subject  of  dispensaries  must  take  each  type  into  consideration.  For 
this  purpose  the  following  outline  will  be  used : 

I.  Medical   Dispensaries — E'xclusivb   op   Tuberculosis    Clinics 
AND  Infantile  Paralysis  Clinics. 

A.  The  General  Dispensary — treating  all  cases, 

(1)  those  with  specialized  departments  and 

(2)  those  without  specialization. 

B.  The  Specialized  Dispensaries. 

(1)   Eye,  ear,  nose  and  throat;  (2)  maternity; 

(3)  women  and  children;    (4)   children;    (5) 
venereal  disease;  (6)  osteopathic 

C.  Chiropractic,  Naprapathic,  and  Nature-cure. 

II.  Tuberculosis  Dispensaries. 

A.  Municipal 

B.  County 

III.  Infantile  Paralysis  Clinics. 

IV.  Dental  Clinics. 

The  general  dispensary. — The  departments  usually  found  in  the 
general  dispensary  are  (1)  General  Medicine,  (2)  Surgery,  (3)  Genito- 
urinary, (4)  Dermatology,  (5)  Laryngology,  (6)  Paediatrics,  (7) 
Gynecology,  (8)  Neurology,  (9)  Opthalmology.  There  may  be  further 
specialization  within  these  various  departments  with  such  sub-depart- 
ments as  orthopedic  surgery,  oral  surgery,  rectal  surgery,  tuberculosis, 
obstetrics,  massage,  speech  and  hydrotherapy.  Some  dispensaries  have 
only  a  few  of  these  departments,  grouping  all  cases  under  the  heads  of 
General  Medicine,  Surgery,  Gynecology,  Paediatrics,  Genito-Urinary 
and  Dermatology,  while  in  others  all  the  departments  named  are  main- 
tained. •  As  shown  in  the  table  above,  27  of  the  105  dispensaries  found 
in  the  State  are  general  dispensaries.  Nineteen  of  these  are  in  Chicago 
and  one  each  in  Springfield,  Peoria,  Evanston,  Oak  Park,  Eock  Island, 


351 

Eockford,  Argo  and  Blue  Island,  respectively.  The  dispensary  in  Oak 
Park  is  maintained  by  Cook  County.  Those  in  Eockford  and  Peoria 
are  maintained  by  social  settlements.  The  others  in  cities  outside  of 
Chicago  are  hospital  out-patient  departments.  Of  the  nineteen  general 
dispensaries  in  Chicago  which  gave  334,649  treatments  last  year,  eleven 
are  affiliated  with  medical  schools.  These  combined  treatment  of  patients 
with  instruction  of  students.  To  these  eleven  institutions  252,449  visits 
were  made  last  year.  The  total  comprised  46  per  cent  of  the  treatments 
given  in  Chicago  dispensaries,  exclusive  of  the  tuberculosis  and  dental 
clinics. 

Five  of  the  general  dispensaries  are  maintained  as  hospital  out- 
patient departments.  One  of  the  five,  the  Emanuel  Mandel  Memorial 
Dispensary,  though  the  out-patient  department  of  Michael  Eeese 
Hospital,  is  located  in  a  different  section  of  the  city  from  the  hospital. 
These  five  dispensaries  had  72,741  visits  last  year.  The  three  other 
general  dispensaries  are  maintained  by  charitable  organizations,  two 
by  church  settlements,  and  one  by  the  Salvation  Army.  The  number 
of  visits  made  to  these  three  dispensaries  last  year  was  9,459. 

Buildings  and  equipment. — Few  dispensaries  occupy  quarters  espe- 
cially designed  for  the  examination  and  treatment  of  patients.  The 
Emanuel  Mandel  Memorial  Dispensary  and  the  Maxwell  Street  Dis- 
pensary of  the  Chicago  Lying-in  Hospital  have  buildings  used  exclus- 
ively for  dispensary  work.  Dispensaries  affiliated  with  medical  schools 
use  rooms  in  some  of  the  college  buildings  which  may  or  may  not  be  well 
adapted  to  the  work  for  which  they  are  used.  Hospital  out-patient  depart- 
ments are  usually  located  in  basements  of  the  affiliated  hospitals.  Dispen- 
saries operated  by  churches  and  settlement  houses  make  temporary  use  of 
the  rooms  in  those  institutions.  The  Sanitary  Code  of  Chicago  requires 
each  dispensary  to  provide  a  suitable  room  for  the  isolation  of  cases  of 
contagious  disease  until  such  patients  shall  have  been  taken  charge  of 
by  the  Department  of  Health.  Such  rooms  must  have  both  "separate 
toilet  facilities  and  a  supply  of  running  water." 

Some  dispensaries  have  one  general  waiting  room  from  which 
patients  are  assigned  directly  to  physicians.  Others  have  a  general 
waiting  room  and  smaller  departmental  waiting  rooms.  In  eleven  out 
of  sixteen  of  the  larger  dispensaries  in  Chicago,  the  general  waiting 
rooms  are  in  the  basements,  making  proper  lighting  and  ventilation 
difficult  and  in  some  instances  unobtainable.  In  some  dispensaries  wait- 
ing rooms  are  frequently  overcrowded.  The  rooms  used  for  treatment 
of  patients  were  in  general  found  to  be  well  lighted  and  ventilated. 

The  Commission  did  not  obtain  much  detailed  information  con- 
cerning the  equipment  of  dispensaries  studied.  In  general  we  may  say 
that  those  dispensaries  affiliated  with  medical  schools  and  hospitals  are 
well  equipped  for  laboratory,  x-ray  and  other  diagnostic  work.  In  most 
other  dispensaries,  if  such  service  is  required,  patients  are  referred  to 
other  clinics  or  to  physicians  with  whom  the  dispensary  has  arranged 
.  for  such  service. 

Equipment  in  modem,  scientific,  diagnostic  and  therapeutic  pro- 
cedure is  essential  to  the  best  medical  service,  and  those  dispensaries 


352 

which  can  place  such  facilities  at  the  command  of  their  physicians  will, 
other  things  being  equal,  give  their  patients  the  best  institutional  medical^ 

service. 

Supervision. — ^Efficient  dispensary  service  is  dependent  in  part  upon 
competent  management.  If  those  who  control  a  dispensary's  policies 
and  direct  its  activities,  realize  the  significance  of  the  work  the  institution 
can  perform  and  plan  to  make  that  work  commensurate  with  public 
health  needs,  such  an  institution  will  be  an  important  part  of  the  com- 
munity's medical  facilities.  If  there  is  not  management  of  this  type,  and 
too  frequently  there  is  not,  a  dispensary's  value  may  be  very  limited. 
From  the  standpoint  of  the  community,  the  value  of  a  dispensary  de- 
pends upon  the  type  and  quality  of  its  medical  service,  upon  the  con- 
tribution it  makes  to  the  health  and  physical  well-being  of  the  people 
it  serves.  Its  relation  to  medical  school,  church,  social  settlement  or 
other  organization  is  significant  only  in  relation  to  this  primary  function. 
Management  of  a  dispensary  is  usually  in  the  hands  of  a  Board  of 
Directors  especially  if  the  institution  is  a  separate  entity.  Dispensaries 
which  are  integral  parts  of  other  institutions  such  as  medical  schools, 
hospitals  or  institutional  churches,  etc.,  are  usually  under  the  control 
of  a  committee  of  the  Board  of  the  institutions  concerned.  If  the  dis- 
pensary is  of  considerable  size  it  is  likely  to  be  better  managed  if  it  has 
a  supervisor  giving  his  full  time  to  the  work.  Two  Chicago  dispensaries 
have  paid  superintendents;  in  other  institutions  the  supervisor  may  be 
the  secretary  of  an  affiliated  medical  school,  a  nurse  assigned  by  the 
hospital  to  its  out-patient  department  or  the  senior  physician  of  the  dis- 
paisary  staff.  These  supervisors,  of  course,  can  give  only  a  part  of  their 
time  to  dispensary  affairs. 

Admission  and  registration. — ^The  admission  system  of  a  well  organ- 
ized dispensary  should  fulfill  three  functions: 

1.  To  register  all  patients  with  sufficient  information  concerning 
each  that  indentification  will  be  possible  at  any  future  time; 

2.  To  obtain  sufficient  information  concerning  each  patient's  com- 
plaint that  he  may  be  assigned  to  the  proper  clinics ; 

3.  To  ascertain  whether  or  not  each  patient  is  financially  qualified 
for  treatment  in  a  dispensary. 

In  the  registration  and  assignments  of  patients  the  first  two  of 
these  functions  seems  to  be  well  taken  care  of  in  most  of  the  Chicago 
dispensaries.  With  reference  to  the  fina.ncial  status  of  patients  con- 
sidered eligible  for  dispensary  service,  standards  vary  from  one  insti- 
tution to  the  other.  Some  dispensaries  exercise  care  in  this  matter, 
while  others  admit  practically  all  who  apply. 

Reports. — Dispensaries  must  report  to  the  local  health  authorities 
all  cases  of  contagious  disease  diagnosed  by  their  physicians.  In  Chicago 
all  dispensaries  must  make  a  monthly  report  to  the  Department  of 
Health  giving  the  number  of  new  and  old  patients  treated  and  classified 
as  to  sex  and  age  group.  They  are  required  to  report  in  considerable 
detail  all  patients  under  their  treatment  for  venereal  disease.  They 
must  also  file  an  annual  report  classifying  all  patients  under  their  re- 
spective diagnosis. 


353 

Records. — Chicago  dispensaries  are  required  by  law  to  keep  a  record 
of  each  patient  stating  age,  sex,  occupation,  diagnosis  and  other  essential 
facts.  Two  or  three  Chicago  dispensaries  have  well  organized  record 
systems  from  which  statistical  information  can  be  drawn.  Most  of  the 
others  have  too  limited  a  clerical  force  to  make  possible  proper  keeping 
of  records. 

Dispensary  service. — The  quality  of  medical  service  furnished  by  a 
dispensary  depends  upon  several  factors.  Of  primary*  importance  is 
the  staff.  The  Commission  made  no  inquiries  concerning  the  qualifi- 
cation of  physicians  serving  on  dispensary  staffs.  Those  dispensaries 
connected  with  high  grade  medical  schools  probaby  have  an  advantage 
in  attracting  medical  men  of  ability.  As  mentioned  above,  equipment 
and  other  facilities  affect  the  quality  of  the  work  an  institution  performs. 
Dispensary  patients  frequently  complain  of  the  long  time  they  have  to 
wait  in  order  to  see  a  doctor.  With  the  present  organization  of  most 
dispensaries  much  of  this  waiting  is  unavoidable.  Doctors  can  give  only 
limited  amount  of  their  time  to  dispensary  work.  If  a  dispensary 
renders  good  service  its  clinics  are  sure  to  be  crowded.  A  greater  diffi- 
culty than  having  to  wait  is  likely  to  befall  the  patients  in  the  more 
widely  patronized  dispensaries— that  of  receiving  but  a  few  minutes 
of  a  busy  doctor^s  time.  In  many  dispensaries  there  are  either  too  many 
patients  or  too  few  doctors  to  make  for  satisfactory  service  from  the 
standpoint  of  either  patient  or  physician.  Ten  Chicago  dispensaries 
hold  night  clinics,  but  six  of  these  are  for  venereal  disease  patients  only. 
One  dispensary  has  established  an  evening  clinic  for  working  people. 
With  these  few  exceptions,  dispensary  facilities  are  unavailable  for  the 
working  man  or  woman  who  is  sick  but  not  too  sick  to  work.  As  men- 
tioned earlier  in  this  report,  the  dispensaries  of  Chicago  are  located 
chiefly  in  two  rather  restricted  are&s.  The  block  studies  show  that  those 
families  living  in  the  vicinity  of  dispensaries  take  much  greater  advan- 
tage of  dispensary  treatment  than  do  those  who  live  at  any  considerable 
distance  from  such  institutions. 

Social  service. — Since  unfavorable  social  conditions  may  cause, 
accompany,  or  result  from  sickness,  the  treatment  of  these  conditions 
becomes  an  important  part  of  efficient  medical  treatment.  Recognition 
of  this  fact  has  led  to  the  establishment  of  social  service  departments 
in  many  of  the  better  hospitals  and  dispensaries.  Such  a  department 
aims  to  supplement  the  work  of  the  doctor  by  giving  attention  to  various 
elements  in  the  patient^s  environment  which  need  correction,  to  problems 
in  the  solution  of  which  he  needs  help  if  the  doctor^s  work  is  to  be  cur- 
ative rather  than  palliative. 

The  dispensary  social  department  is  usually  charged  with  the  re- 
sponsibility of  seeing  that  patients  who  need  to  continue  under  treat- 
ment for  some  time  come  to  the  institution  as  long  as  observation  and 
treatment  seem  necessary.  This  work  is  commonly  known  as  "follow- 
up."  The  patient  suffering  from  disease  which  requires  a  considerable 
period  of  treatment  gets  little  benefit  from  one  visit  or  a  .few  visits. 
Efficient  "follow-up"  through  securing  the  cooperation  of  the  patient, 

—23  H  I 


354 

through  writing  to  him  or  visiting  him  if  he  interrupts  his  treatment, 
has  greatly  increased  dispensary  efficiency.  Correction  of  living  and 
working  conditions  are  often  essential  to  successful  medical  treatment. 
Seeing  that  such  corrections  are  made  is  another  function  of  the  Social 
Service.  Arrangements  for  dental  service,  for  hospital  care,  for  con- 
valescent care,  for  home  nursing,  etc.  are  frequently  made  through  a 
social  service  department.  Through  this  department,  acting  as  a  clear- 
ing house,  patients  may  be  referred  to  any  of  the  community's  social 
organizations  whose  service  they  may  need.  Agencies  such  as  nursing 
organizations,  relief  societies,  child  welfare  agencies,  and  the  like  refer 
many  patients  to  dispensaries  for  diagnosis  and  treatment.  Social 
service  departments  see  to  it  that  these  agencies  are  informed  as  to  the 
diagnosis  and  prognosis  of  patients  so  referred.  Six  Chicago  dispen- 
saries maintain  social  service  departments.  In  four  others  a  visiting 
nurse  is  employed  to  do  home  nursing.  In  five  others  affiliated  with 
charitable  organizations,  social  workers  do  some  dispensary  work  in 
connection  Avith  other  duties.  Twelve  dispensaries  have  no  social  service 
or  follow-up  work  of  any  sort.  In  dispensaries  outside  of  Chicago 
social  service  for  patients  is  frequently  secured  through  cooperation  with 
public  health  nurses,  organized  charity  Avorkers  and  the  like. 

Social  service  registration  bureaus. — Chicago  has  two  social  service 
registration  bureaus  or  confidential  exchanges  as  they  are  sometimes 
called.  One  is  operated  in  connection  with  the  United  Charities  and 
the  other  by  the  Associated  Jewish  Charities.  Various  social  and 
philanthropic  agencies  register  the  persons  whom  they  sevYe  with  one  or 
the  other  of  these  bureaus.  From  such  registration  any  agency  may 
ascertain  what  other  agencies  or  institutions  are  serving  or  have  served 
an  individual  or  family.  The  use  of  these  bureaus  by  dispensaries 
would  give  them  valuable  data  concerning  their  patients,  and  would 
acquaint  other  agencies  with  the  fact  that  persons  in  whom  they  are 
interested  are  under  dispensary  medical  treatment.  At  the  time  the 
investigation  was  made  five  of  the  privately  conducted  dispensaries  and 
the  Municipal  Tuberculosis  Dispensaries  were  registering  their  patients 
with  these  bureaus. 

Dispensary  abuse. — As  dispensaries  have  increased  in  number  and 
as  their  work  has  increased  in  volume,  there  has  been  the  not  infrequent 
criticism  on  the  part  of  individual  physicians  and  medical  societies,  that 
dispensaries  bestow  medical  charity  upon  people  who  have  no  valid 
claim  to  it  and  who  can  well  afford  to  pay  for  medical  service.  As  long 
as  dispensaries  are  primarily  charitable  institutions  in  which  doctors 
receive  no  financial  compensation  for  their  services,  they  should  be  care- 
ful, as  should  other  charitable  agencies,  to  see  that  only  those  who  need 
such  free  service,  receive  it.  Dispensaries  differ  greatly  from  each  other 
as  to  the  care  they  exercise  in  limiting  their  service  to  bona  fide  mem- 
bers of  the  charity  group.  Some  admit  every  applicant;  others  make 
financial  investigations  of  practically  all  their  patients  and  exclude  all 
whose  incomes  are  above  a  fixed  standard ;  still  others  fall  between  these 
two  extremes,  taking  what  seem  to  them  to  be  reasonable  precautions 
to  keep  out  the  financially  ineligible. 


Careful  investigations  have  been  made  at  different  times  in  Boston, 
New  York,  St.  Louis  and  other  cities  of  a  considerable  number  of  dis- 
pensary patients,  to  ascertain  their  claim  to  fiee  medical  service.  These 
investigations  have  shown  that  only  a  small  percentage,  from  two  to  five, 
of  dispensary  patients  are  really  able  to  pay  for  the  medical  service  they 
seek  to  obtain  free  or  at  nominal  cost. 

In  our  study  of  2,869  (heie  are  included  only  those  families  for 
whom  complete  statements  could  be  obtained)  families  in  Chicago 
(charity  cases  excluded)  it  was  found  that  511  families,  or  17.8  per 
sent,  had  received  some  foim  of  dispensary  service  for  one  or  more  ^mem- 
bers within  the  preceding  twelve  months.  Budget  studies  made  in 
North  Chicago  and  investigations  made  by  the  Bureau  of  Labor  Statis- 
tics and  by  the  War  Labor  Board  indicate  that  for  a  family  of  five  (man, 
wife  and  three  children  under  15)  an  income  of  $1,700  per  year  is 
necessary  to  meet  all  normal  family  expenses  including  average  sickness 
costs.  tJsing  this  figure  as  a  basis  of  classification  of  the  2,869  families, 
we  find  that  1,717  had  incomes  of  $1,700  or  over,  or  equivalent  sums  for 
smaller  or  larger  families,  as  against  1,152  with  smaller  incomes.  Of 
the  511  families  receiving  dispensary  service,  102  were  in  the  group  with 
the  larger  incomes  (with  a  minimum  of  $1,700  or  its  equivalent).  Of 
these  102  families,  24  were  given  service  in  municipal  tuberculosis  clinics, 
infant  welfare  stations  or  in  special  clinics  established  for  aftercare  of 
infantile  paralysis,  which  institutions  for  obvious  reasons  do  not  limit 
their  services  to  any  economic  group.  This  leaves  78  families  in  the 
higher  income  gi'oup  receiving  medical  advice  and  treatment  in  dis- 
pensaries which  in  general  confine  their  service  to  people  of  very  limited 
income.  These  78  families  are  15.2  per  cent  of  the  511  families  with  dis- 
pensary records. 

It  is  well  to  bear  in  mind,  however,  that  the  type  of  medical  service 
needed  is  important  in  determining  whether  or  not  a  patient  is  worthy 
of  dispensary  treatment.  One  may  be  well  able  to  pay  a  general  prac- 
titioner for  treatment  of  a  minor  ailment  or  one  of  short  duration,  but 
unable  to  pay  for  a  specialist's  service  if  needed  or  for  treatment  con- 
tinuing through  a  long  period  of  time.  On  the  basis  of  type  of  service 
needed  these  78  families  divide  into  55  whose  condition  of  illness  indi- 
cated the  need  of  specialist  service  and  23  who  presumably  could  have 
obtained  all  needed  service  from  a  general  practitioner.  From  this 
analysis  we  may  conclude  that  23  families  out  of  a  total  of  511,  or  4.5 
per  cent,  were  recipients  of  medical  charity  which  their  economic  status 
did  not  justify.  This  figure  closely  approximates  the  findings  of  the 
the  investigations  in  Boston,  New  York  and .  St.  Louis  mentioned  above. 

The  public  health  dispensaries,  for  example  those  conducted  by 
infant  welfare  organizations  and  by  public  or  private  agencies  for  the 
treatment  of  tuberculosis,  usually  treat  all  who  apply  regardless  of 
financial  ability.  If  pay  clinics  are  established  and  with  them  a  system 
of  compensating  dispensary  physicians  for  their  services,  the  question  of 
dispensary  abuse  will  tend  to  disappear. 


356 

i^ee^.— Dispensaries  vary  considerably  in  the  charges  patients  are 
asked  to  pav,  either  for  service,  drugs  or  appliances.  Some  institutions 
make  no  charges  whatever,  while  others  request  patients  to  pay  lees 
approximating  the  cost  of  private  service.  In  practically  all  cases  those 
who  cannot  pay  admission  or  other  fees  are  treated  free.  Most  dispen- 
saries act  on  the  principle  that  small  payments  on  the  part  of  patients 
make  for  better  cooperation  between  patient  and  institution. 

(a)  Admission  fees.— ^ome  dispensaries  have  no  admission  fee; 
some  charge  ten  cents  to  cover  cost  of  registration;  some  make  a  flat 
rate  qf  twenty-five  cents  to  cover  both  admission  and  prescription  fee. 
The  accounts  of  most  dispensaries  were  found  to  be  so  kept  that  it  is 
impossible  to  obtain  the  proportion  of  patients  paying  these  fees. 

(b)  Bmgs, — Charges  for  drugs  vary  from  ten  cents  included  m  the 
admission  fee  to  a  rate  of  25  to  50  cents  for  prescription  up  to  the  cost 
of  drugs.  Some  charge  10  per  cent  more  than  cost  to  pay  a  part  of  the 
overhead  expenses.  This  is  done  by  dispensaries  which  charge  a  small 
admission  fee  or  have  no  such  fee  at  all. 

(c)  G^/fls^e^.— Institutions  which  secure  glasses  for  patients  charge 
a  rate  varying  from  the  cost  price  up  to  the  cost  plus  10  per  cent.  The 
common  policy  is  to  charge  dispensary  patients  the  wholesale  rate. 
Some  dispensaries  refer  patients  who  are  unable  to  pay  for  glasses  to 
charity  bureaus  some  of  which  have  arranged  with  optical  concerns  for 
free  glasses  for  their  beneficiaries.  Some  dispensaries  have  arrange- 
ments with  optical  companies  which  furnish  glasses  to  dispensary  patients 
at  gveatly  reduced  rates. 

(d)  Wassermcmn  tests,  salvarsan,  etc. — The  charges  for  Wassermann 
tests  vary  from  50  cents  up  to  regular  charge  of  $5.  If  patients  cannot 
pay,  such  tests  are  made  free  of  charge  in  some  dispensaries.  Other  in- 
stitutions refer  all  indigent  patients  needing  Wassermann  tests  to  the 
Health  Department  Laboratory  at  the  Iroquois  Memorial  Hospital  which 
makes  such  tests  free  of  charge.  Charges  for  salvarsan  treatment  vary 
from  $2  to  $7.50.  A  few  dispensaries  furnish  such  treatment  free  to 
patients  who  cannot  pay  for  it. 

(e)  X-rays. — The  charges  for  x-ray  service  vary  from  one  dollar  up 
to  the  regular  rate  charged  by  x-ray  laboratories.  Some  dispensaries 
charge  simply  the  cost  of  the  service;  one  charges  cost  plus  10  per  cent, 
while  in  another  patients  are  given  a  25  per  cent  discount  from  the 
regular  commercial  price.  Some  dispensaries  give  x-ray  service  to 
patients  who  cannot  pay. 

(f)  Tonsillectomies. — Dispensaries  which  are  affiliated  with  hos- 
pitals perform  tonsillectomies,  arranging  for  the  patient  to  stay  at  least 
twenty-four  hours  in  the  hospital.  Charges  for  this  service  range  from 
$3  to  $10  including  hospital  bed  fee.  In  some  dispensaries  such  service 
is  given  to  patients  who  are  unable  to  pay  for  it. 

Accounts — receipts  and  expenditures,  deficits. — Only  one  or  two  dis- 
pensaries investigated  were  operated  at  a  profit.  In  fact  practically  all 
of  them  are  dependent  upon  other  sources  of  income  than  patients  for  a 
considerable  part  of  their  operating  expenses.  The  accounting  systems 
in  general  were  found  to  be  poor.     Frequently  dispensary  accounts  are  not 


35: 

beparated  from  accounts  of  the  affiliated  institutions.  Actual  cost  of 
maintenance  is  therefore  impossible  to  obtain.  The  average  cost  per 
patient's  visit  was  found  to  vary  from  11  cents  in  institutions  in  which 
costs  of  heat,  light,  rent,  etc.  were  not  included,  to  78  cents  in  the  case 
of  one  Chicago  dispensary  with  all  such  expenses  included.  It  must  be 
borne  in  mind,  however,  that  practicaJly  all  of  the  medical  service  in 
dispensaries  is  given  free  of  charge  by  the  attending  physicians. 

In  Springfield,  the  county  of  Sangamon  maintains  a  dispensary  as 
the  out-patient  department  of  St.  John's  Hospital.  The  hospital  furn- 
islies  several  rooms  for  dispensary  work  and  provides  drugs  and  special 
forms  of  treatment  at  reduced  rates.  The  hospital  is  reimbursed  by  the 
county  for  the  amount  thus  spent.  The  dispensary  treated  10,061 
patients  last  year  and  was  reimbursed  by  the  county  in  the  amount  of 
$4,107.05. 

Conclusions. — The  Commission's  investigation  has  shown  that  dis- 
pensaries are  important  factors  in  providing  medical  service  for  the 
poor,  and  for  people  of  moderate  means.  The  location  of  Chicago  dis- 
pensaries is  not  well  adapted  to  the  needs  of  the  people  for  ready  access 
to  such  institutions.  Many  dispensaries  need  improved  quarters,  equip- 
ment and  record  systems,  and  more  doctors,  social  workers,  clerks,  etc. 
Fundamentally  the  problem  of  better  dispensary'  service  is  a  question  of 
more  generous  support  on  the  part  of  the  community.  Dispensaries  are 
a  part  of  the  community's  equipment  for  protection  against  disease  and 
for  health  conservation,  and  in  the  long  run  a  community's  health  bears 
a  close  relation  to  what  it  is  willing  to  spend  for  such  protection  and  con- 
servation. 

The  following  table  has  been  made  to  show  in  summary  form  for  the 
more  important  dispensaries  investigated  in  Chicago,  certain  outstanding 
facts. 


358 


SUMMARY  TABLE  FOR  CERTAIN  GENERAL 


General 
dispensaries. 


o 

a 

Equip- 
ment. 

Physicians. 

Admission  fees. 

D 

o 

Vi    CO 

5  ®   -v. 

4.3 

tJ 

CJOT 

eceipts 
patient 

xpendil 
light,  h 
salaries 
supplie 

>> 

ab  ora- 
tory. 

o 

a 

umber 
paid. 

m 

> 

2 

r-   TO 

G 

Eh 

« 

W 

X 

^      1 

;z; 

Z 

Ph 

« 

0 

Drugs. 


<a 


1 

2 

3-4-5. 

6 

7 


8.. 
9.. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19.' 


Special    dispensa- 
ries— 

IE.  E.N.  T.. 

2E.  E.  N.  T.. 

3  W.  &Ch.... 

4  W.&Ch.... 
5W.  &Ch.... 
6W.&Ch.... 

7Ch 

8Ch 

9Cli 

10  Ch 

llObstet.... 

12  0bstet.... 

13  Ven.  Dis.. 

14  Ven.  Dis.. 

15  Osteop 


74,600 
24,281 
11.000 
24,399 
15,827 

32,157 

35,000 

25,000 

10,185 

2,670 

44,769 

2,114 

4,675 

3,000 

1,986 

17,860 

5,126 

16,627 

74, 151 

1,149 

3,228 

8,030 

848 

4,212 

28,603 

2,500 

10,738 

3,917 

19,430 

195 

9,360 

2,510 


$25,571 

1,413 

600 

3,771 

5,259 

10,673 

N.  R. 

N.  R. 

N.  R. 

492 

8,009 

283 

0 

600 

471 

0 

N.  R. 

N.  R. 

0 

383 

400 

N.  R. 

N.  R. 

10 

0 

0 

0 

461 

4,357 

N.  R 

0 

N.  R 


$  35,120 
4,500 
5,400 
5, 132 
6,620 

8,612 
N.  R. 
N.  R. 
N.  R. 

1,515 
43, 120 

1,115 
489 

1,000 

655 

N.  R. 

N.  R. 


N.  R. 

N.  R. 

427 

2,520 
N.  R. 
N.  R 

1,284 

9,725 
N.  R. 
N.  R. 

2,972 
17,403 
N.  R. 
N.  R 
N.  R 


Yes. 
Yes. 
Yes. 
Yes. 
Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 


No. 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

No. 

No. 

Yes. 

Yes. 


Yes. 
Yes. 
Yes. 

Yes. 
Yes. 

Yes. 

Yes. 

Yes 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No.  . 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

No. 

Yes. 

Yes. 

Yes. 


110 
29 
45 
20 
50 

60 

60 

54 

50 

5 

50 

9 

3 

16 

16 

3 

9 

16 
40 
3 
1 
10 
2 
2 
16 
10 
9 
N.  R. 
16 
10 
6 
12 


7 
0 
1 
0 
1 

0 
0 
0 
0 

1 

3 
0 
0 
0 
0 
3 
2 

0 
10 
0 
1 
0 
0 
2 
0 
0 
0 
N.  R. 
0 
0 
6 


25c 
0 
0 
0 

10c 

0 

10c 

25c 

10c 

15c 

15c 

10  to  50c 

0 

0 

0 

0 

15c 

50c 

0 

10c 

10c 

10c 

10c 

0 

0 

0 

0 

0 

0 


25c  to 

50c 

0 

$3  per 
mo 


10c 
0 
0 
0 

10c 

0 

0 

25c 

10c 

15c 

15c 

10  to  50c 

0 

0 

0 

0 

15c 


0 

0 

10c 

10c 

10c 

10c 

0 

0 

0 

0 

0 

0 

25c  to 

50c 

0 


Yes. 
Yes. 
Yes. 
Yes. 
Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 


Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

No. 

No. 

Yes. 

Yes. 

No. 


10c 

10c 

15c 

Cost 

Cost-l- 
10% 

Cost 

Cost 

0 

Cost 

0 

15c 

25c  to  50c 

0 


Cost 
0 

Cost 

35c 
0 
25c 
10c  to  15c 
Cost 


Cost 
Cost 


359 


AND  SPECIAL  DISPENSARIES  IN  CHICAGO. 


Glasses. 

Wassennann 
tests. 

Tonsillec- 
tomies. 

X 

-ray. 

Social  service. 

Dispensary  hours. 

Secured  for 
patients. 

© 

05 

1 

• 

■*-► 
cU 

i 

03 

to 

• 

03 
ft 

-1^ 

•a 

•  i-H 

Yes. 
Yes. 

Cost+ 

Cost  + 
15c 

Cost 

Coxt+ 
10% 

Up  to 
$3.00 

Cost 
Cost 
Cost 
Cost 
Cost 

Cost 
Cost 

Retail 

price 

Cost 

Cost 
Cost 

Cost 
Cost 

Cost 

Yes. 
Yes. 
Yes. 
Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

No. 

Yes. 

Yes. 

Yes. 

$1.00 

0 

$2.00 

Up  to 
$5.00 

Up  to 
$2.50 

Up  to 
$5.00 

50c  to 
$2.00 

Up  to 
$5.00 
$1.00 

0 

0 

$2.00  to 
$5.00 
$5.00 

$5.00 

$2.00 

$3.00  to 
$5.00 

0 
0 

■ 

0 
0 

$2.00 

Yes. 
Yes. 
Yes. 
Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

No. 

No. 

No. 

Yes. 

$4.50 

0 

$3.00 

Hosp. 
fee. 

0 

Up  to 

$5.00 

Hosp. 

fee. 

Hosp. 

fee. 

$3.00 

Hosp. 

fee. 
Hosp. 

fee. 
Hosp. 

fee. 

$5.00 

$6.50 

0 

$7.50 

$10.00 

0 

$3.00 

$5.00 

0 
0 

$5.00 

Yes. 
Yes. 
Yes. 
Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

No, 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

Ntf. 

No. 

Yes. 

Yes. 

$l-$2 

50c- 

$1.00 

$1.00  up 

Up  to 
$25.00 

Cost+ 
10% 

Up  to 

$25.00 

Cost 

Up  to 
$25.00 
Regular 
rates. 

Yes. 
Yes. 
No. 
No. 

Yes. 

No. 
No. 
No. 
Yes. 

5 

1 

8:30-4 

9-12;  2-4 

2-4 

9-5 

9-5 

9-5 

10-12;  2-4 

9-6 

10-12;  2-4 

10-12 

9-11;  1-4 

9-12 

12-1:30 

except  Sat. 

12-6 

9-12 

9-3 

9-11 

1:30-3 

1:30-3 

12-3 

1-4 

9-12;  1^ 

Tu.-F.    3-5 

8-10 

9-5 

1-5 

^5 

Tu.-Th.  3-4 

All  day 

9-10;  2-3 

Tu.-Fr. 
6:30-8 

No. 

All  7-8 

Yes. 

Yes. 
Yes. 

2 

G.  U.  Mon. 

and  Thur. 

7-9 

No. 

Use 
V.  N.  A. 

Yes. 

Yes. 
Yes. 

1 
2 
6 

G.U.Tues. 
7-11 

Yes. 

$1.00 

$2.00  to 
$10.00 

$3. 00  to 

$10.00 

0 

Cost 

........ 

0 

Yes. 
No. 

No. 
No. 

No. 
No. 
No. 

Yes. 

Mon.  and 

No. 

Thur.  7-9 

No. 

6-8 

Yes. 

1 

Hosp. 

1 

No. 

Yes. 

Yes. 

Yes. 

0 
0 

1 

Yes. 
No. 

6:30-7:30 

Yes. 

Cost 

No. 

No. 

1 

u.  c. 

8 

1 

No. 

Yes. 

0 
0 

Yes. 

Yes. 

No. 

Yes. 

No. 

No. 

No. 

Yes. 

No. 

2 

No. 

All  day 

No. 

6:30-8:30 

No. 

Dept.  of 
health 

I  6:30-8:30 
Tu.-Fr.  7-9 

Yes. 

Cost 

No. 

T.-Th.  1-4; 

M.-W.-F. 

1-5 

360 


SUMMji^RY  TABLE  FOR  CERTAIN  GENERAL 


General 
dispensaries. 


o 


ft  ^j 
O  > 


a 


O  K) 

CO       3 

5  ® 


a> 


©:-H 


Equip- 
ment. 


08     • 

O  ui 
.Q  O 


Physicians. 


<9 

05     . 

,Q 

.Q-O 

a 

a -3 

s 

S  Ph 

iz; 

iz; 

Admission  fees. 


CO 


E^ 


rj  CO 

S    CO 

©  > 


Drugs. 


© 

CO 

© 
ft 
CO 


© 
O 


leChiro... 

17  Nature  Cure 

18  Naprap 

19  Dental 

20  Dental 

21  Dental 

22  Dental 

23  Dental 

24Tbc 


11,000 

1,500 

7,000 

Yes. 

No. 

6 

6 

$1.00 

$1.00 

2,400 
5,220 

88,000 

N.  R. 
N.  R. 

N.  R. 

N.  R. 
N.  R. 

N.  R. 

Yes. 

No. 

Yes. 

No. 
No. 

Yes. 

6 
2 

30 

6 
2 

30 

$1  per 
week 
$20.00 
for  36 
visits 
0 

0 

32,000 

N.  R. 

N.  R. 

Yes. 

Yes. 

15 

6 

0 

0 

3,012 

N.  R. 

N.  R. 

Yes. 

Yes. 

2 

2 

0 

0 

60,000 

N.  R. 

N.  R. 

Yes. 

Yes. 

12 

12 

0 

0 

49,420 

0 

N.  R. 

No. 

No. 

10 

10 

0 

0 

63,587 

0 

343,444 

No. 

No. 

20 

20 

0 

0 

No. 
No. 
No. 


Yes. 


i 


Cost  of 
material 

Cost  of 
material 

Cost  of 
material 

Cost  of 
material 

Cost  of 

material 

0 


361' 


AND  SPECIAL  DISPENSARIES  IN  CHICAGO — Concluded. 


Glasses. 


O    IM 

O    Q, 


o 

03 


Wassermaiin 
tests. 


05 

P5 


Tonsillec- 
tomies. 


■    ^ 


X-ray. 


03 


OJ 


Social  service. 


(-1  s 


o 


Dispensary  hours. 


03 


4.9 

xi 


No. 
No. 
No 

No. 

No. 
No. 
No. 
No. 
No. 


Yes. 
No. 

$5.00 

No. 

No. 

Yes. 
Yes. 

$8.00 

and  up 

$3.00  up 

No. 
No. 

No. 

No. 

No. 

No. 

No. 
No. 

No. 
No. 

Yes. 
Yes. 

25c  to 
50c 
25c 

No. 
No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 
Yes. 

No. 

0 

No. 
Yes. 

> 

0 

No. 
No. 

0 

Yes. 

2-3 
2-5 
3-4 

9-5 
9-5 
10-12;  1-6 
9-5 
9-3 
9-5 


Tu.-Fr.  7-9 


6-8 


Tu.-Fr.  7-9 


362 

Tuberculosis  dispensaries.— The  treatment  of  tuberculosis  by  the 
dispensary  method  has  been  greatly  developed  in  Illinois  within  the  last 
few  years.  The  State  Campaign  against  Tuberculosis  is  elsewhere  treated 
in  this  report.!  So  far  as  institutional  treatment  of  tuberculosis  is  con- 
cerned, this  work  was  formerly  done  chiefly  in  a  department  of  a  general 
dispensary,  but  as  specialization  in  the  treatment  of  this  disease  developed 
ajid  as  organizations  both  public  and  private  assumed  the  task  of  pro- 
viding treatment,  special  tuberculosis  dispensaries  and  sanitaria  have  been 

established. 

In  the  State  of  Illinois  there  are  at  present  26  tuberculosis  dis- 
pensaries. Eight  of  these  are  in  Chicago,  five  are  in  Cook  County  outside 
of  Chicago  and  thirteen  are  in  the  State  outside  of.  Cook  County. 

The  eight  Municipal  Tuberculosis  Dispensaries  in  Chicago  are 
operated  by  the  Dispensary  Department  of  the  Municipal  Tuberculosis 
Sanitarium.  No  charge  is  made  to  patients  treated;  nurses  visit  the 
homes  of  all  patients  treated  and  give  instruction  as  to  care  and  hygiene. 
Twenty  full  time  physicians  are  employed,  their  salaries  ranging  from 
$2,500  to  $3,500  per  year.  Dispensary  hours  are  from  9  to  5  daily  except 
Saturday  and  Sunday^9  to  1  Saturday,  and  on  Tuesday  and  Friday 
evening  clinics  are  held.  One  physician  is  on  duty  in  each  dispensary 
during  dispensary  hours  while  from  each  dispensary  one  physician  is 
visiting  patients'  homes  or  doing  survey  work.  In  1917  these  dispensaries 
treated  17,953  new  patients  giving  56,394  clinical  treatments,  total  num- 
ber of  visits  made  by  patients  was  77,978.  The  cost  of  this  dispensary 
service  to  the  people  of  Chicago  for  the  year  1917  was  $343,443.74. 

Cook  County,  through  its  Bureau  of  Social  Service  and  the  Chicago 
Tuberculosis  Institute  conjointly  support  and  control  five  tuberculosis 
dispensaries  outside  of  Chicago.  These  are  located  in  Argo,  Blue  Island, 
Oak  Park,  Arlington  Heights  and  Oak  Forest.  These  five  institutions 
were  recently  organized  and  as  yet  have  not  been  extensively  utilized. 
They  are  open  from  one  to  three  hours  on  certain  days  of  the  week.  Phy- 
sicians in  these  dispensaries  are  not  paid.  Social  service  and  follow-up 
work  is  done  by  nurses  either  in  the  service  of  the  County  or  Chicago 
Tuberculosis  Institute.  In  the  State  outside  of  Cook  County  there  are 
thirteen  tuberculosis  dispensaries.  All  of  these  dispensaries,  with  the 
exception  of  the  one  in  Springfield,  have  been  organized  within  the 
two  years.  In  1917,  4,253  treatments  were  given  in  five  of  these  dis- 
pensaries. The  other  five  make  no  report  as  to  the  number  of  new 
patients  or  the  number  of  visits  to  the  dispensary.  No  charges  are  made 
to  patients  and  physicians  for  the  most  part  donate  their  services  although 
in  three  dispensaries  one  salaried  physician  is  employed.  These  dis,- 
pensaries  are  open  on  certain  days  of  the  week  and  at  certain  specified 
hours.  Visiting  nurses,  charity  organizations  and  other  agencies  co- 
operate with  these  dispensaries. 

The  treatment  of  tuberculosis  differs  from  the  treatment  of  most 
other  diseases  in  the  regularity  and  frequency  of  the  treatment  neces- 
sary. A  person  of  even  moderate  circumstances  has  difficulty  in  meet- 
ing the   expenses   of   constant  treatment,   and   the   campaign   against 

*  Part  I,  Chapter  II,  Section  4. 


363 

tuberculosis  has  such  general  acceptance  that  there  is  little  opposition 
to  the  granting  of  this  dispensary  service  to  all  who  apply.  Hence 
the  question  of  dispensary  abuse  is  rarely  raised. 

As  counties  are  rapidly  taking  advantage  of  their  power  to  levy 
an  extra  tax  for  the  maintenance  of  tuberculosis  work,  the  number  of 
tuberculosis  dispensaries  in  the  State  will  show  a  marked  increase  in 
the  next  few  years. 

Infantile  paralysis  clinics. —  (From  the  Report  of  Dr.  C.  W.  East 
to  the  Department  of   Public   Health.) 

The  Division  has  conducted  clinics  for  the  after  care  of  infantile 
paralysis  at  weekly  and  bi-weekly  intervals  at  Springfield,  Chicago 
Heights,  Blue  Island,  Oak  Park,  Evanston,  Joliet,  Ottawa,  Eock  Island, 
Moline  and  Quincy. 

Our  bi-weekly  clinics  show  that  we  have  averaged  175  patients  per 
clinical  week  in  the  territory  of  the  State  outside  Springfield.  The 
Springfield  clinics  averages  30  patients  per  week  which  brings  the  aver- 
age bi-weekly  clinical  attendance  to  235.  If  averaged  on  a  weekly 
basis,  this  Division  of  your  department  ministers  directly  and  personally 
to  117  crippled  patients  per  week.  Our  figures  show  that  of  this  at- 
tendance upon  the  clinics  80  per  cent  were  crippled  by  infantile  paralysis, 
and  20  per  cent  by  other  diseases  such  as  tuberculosis,  rickets,  cerebral 
palsy,  and  injury. 

County  and  city  authorities,  clubs  and  individuals  have  contributed 
to  the  brace  and  supply  fund,  which  has  been  administered  by  local 
agencies,  and  to  such  a  degree  of  completeness  that  no  child  for  whom 
a  brace,  surgical  operation  or  hospitalization  has  been  necessary  has  had 
to  do  without  it.  About  $2,500  has  been  thus  contributed  entirely  by 
local  initiative.  Your  representative  has  not  passed  the  hat.  The 
people  have  come  to  the  clinics,  they  have  heard  and  seen  and  have  pro- 
vided fully  all  supplies  needed. 

Several  cities  are  now  urging  the  establishment  of  clinics,  offering 
us  complete  hospital  and  follow-up  facilities.  The  needs  are  as  wide  as 
the  extent  of  the  crippled  population  of  the  State.  These  needs  are 
yearly  augmented  by  fresh  crops  from  epidemic  paralysis. 

Dental  Clinics. — Differing  greatly  from  the  medical  dispensary  as 
to  the  nature  of  their  administration  are  the  dental  dispensaries.  There 
are  four  regular  dental  clinics  in  the  city  of  Chicago,  and  until  recently 
there  were  fourteen  dental  clinics  for  school  children  operated  by  the 
division  of  Child  Hygiene  and  the  Department  of  Health.  Besides 
these  there  is  one  dental  clinic  in  LaSalle  County  also  conducted  for 
school  children.  Three  of  the  Chicago  dental  clinics  are  departments 
of  regular  dental  schools.  In  these  clinics  all  clinical  operations  are 
performed  by  students.  Patients,  unless  referred  by  charitable  organi- 
zations, pay  the  cost  of  all  materials  used.  No  charges  are  made  for  ex- 
tractions, and  no  inquiries  are  made  concerning  the  financial  standing  of 
patients.  These  three  clinics,  which  are  open  from  9  a.  m.  to  5.  p.  m. 
daily,  have  fifty-seven  dentists  on  their  staffs  of  whom  48  are  paid. 
These  dentists  do  little  of  the  treatment  work;  however,  180,000  treat- 
ments were  given  in  these  three  institutions  last  year.     A  fourth  clinic 


364 

is  operated  by  a  school  of  mechanical  dentistry.  Eegular  doctors  of 
dental  surgery  perform  all  extractions,  make  fillings,  impressions,  etc. 
Students  make  plates  and  bridge  work  from  these  impressions.  Patients 
are  charged  minimum  prices.  Three  thousand  and  twelve  treatments 
were  given  in  this  institution  in  1917. 

The  school  clinics  operated  by  the  Chicago  Department  of  Health 
employed  10  dentists  in  1917  working  full  time  in  ten  clinics  located  in 
different  sections  of  the  city.^  In  1917,  49,420  treatments  were  given  in 
these  clinics.  School  health  officers  make  examinations  and  advise 
parents  of  dental  defect.  The  school  nurse  then  follows  up  this  noti- 
fication to  the  parents.  If  the  family  is  unable  to  pay  for  dental  work, 
the  work  is  done  in  the  school  dispensary.  The  Hygienic  Institute  in 
LaSalle  does  a  similar  work.  No  statistical  information  was  available 
from  this  clinic. 


'  The  number  of  cUnics  vrsis  reduced  to  6  in  1918. 


365 


SPECIAL  REPORT  IV.     OCCUPATIONAL  DISEASES  IN 

ILLINOIS. 

(By  Alice  Hamilton,  M.  D.) 


[Note  hy  the  Seci'etary. — A  special  Commission  created  by  the  Illinois  Legisla- 
ture made  an  investigation  of  occupational  diseases  in  Illinois  and  reported  its 
findings  in  1911.  Only  a  very  extensive  and  most  thorough  investigation  by  this 
Commission  of  such  diseases  would  have  been  justified.  Neither  the  time  nor  the 
funds  were  available  for  such  an  investigation.  Moreover,  it  would  have  been  im- 
possible to  obtain  the  services  of  experts  in  this  field  during  the  wai-.  Accordingly, 
the  Commission  decided  it  advisable  not  to  make  an  investigation  of  occupational 
diseases  in  Illinois.  But,  fortunately,  the  Commission  had  among  its  members  Dr. 
Hamilton  who  eight  years  ago  directed  certain  of  the  investigations  for  the  Illinois 
Commission  on  Occupational  Diseases.  For  years  she  has  been  employed  by  the 
U.  S.  Bureau  of  Labor  as  an  expert  investigator  in  this  field,  and  her  investigations 
for  that  Bureau  have  enabled  her  to  keep  in  touch  with  the  situation  in  Illinois. 
Beca.use  of  these  qualifications  Dr.  Hamilton  was  asked  to  prepare  a  summary 
statement  of  occupational  diseases  in  this  State.  Her  summary  statement  is  made 
in  response  to  this  request,  and  is  presented  here.] 

It  is  difficult  to  say  just  what  is  an  occupational  disease.  Cases  of 
poisoning  from  a  substance  which  is  used  in  industry,  and  which  sets 
up  a  definite  train  of  symptoms,  can  be  easily  recognized  and  present  no 
difficulty.  If  a  steel  foundry  man  falls  unconscious,  overcome  by  carbon 
monoxide  gas  from  a  blast  furnace^  the  case  is  accepted  without  question 
as  caused  by  the  occupation.  But  if  a  presser  in  a  poorly  ventilated 
tailor  shop,  where  the  air  is  contaminated  with  carbon  monoxide  from 
the  gas  jets,  is  suffering  from  anaemia  and  neurasthenia  it  is  very  hard 
to  establish  a  connection  between  his  occupation  and  his  sj^mptoms.  It 
is  easy  to  diagnose  lead  poisoning  in  a  painter  with  colic  and  wrist  drop, 
but  much  harder  to  recognize  it  in  a  compositor  who  has  general  harden- 
ing of  the  arteries. 

Acute  occupational  poisoning  is  a  fairly  simple  problem.  Chronic 
occupational  poisoning  is  much  more  difficult.  But  most  difficult  of 
all  is  an  occupational  disease  that  is  caused  not  by  a  poison,  but  by  some 
other  form  of  injury.  Industrial  tuberculosis  is  one  of  the  occupational 
diseases  which  presents  great  difficulty,  because,  though  there  are  some 
dusty  trades  with  a  tuberculosis  rate  so  greatly  in  excess  of  the  average 
as  to  show  beyound  doubt  that  the  occupation  is  in  some  way  related  to 
the  disease,  yet  it  is  hard  to  prove-  that  any  indi\ddual  case  is  to  be 
attributed  to  the  man's  work  and  not  to  something  in  his  life  outside  of 
the  work  shop.  Even  more  difficult  is  it  to  establish  the  responsibility 
of  an  industry  when  the  factors  that  produce  disease  are  fatigue,  over- 
work and  low  wages.  We  know  that  fatigue  lowers  resistance  to  the 
germs  of  disease,  and  that  chronic  fatigue  brings  in  its  train  serious  dis- 
turbances of  nutrition  and  of  the  nervous  system.  But  to  prove  that 
an  over-long  working  da}^,  or  too  heavy  work,  is  responsible  for  these 
symptoms  in  any  one  man  or  woman,  is  well  nigh  impossible.  The  same 
thing  is  true  of  the  ill-health  which  is  caused  by  low  wages.     That  low 


366 

wages  mean  insufficient  or  improper  food,  poor  living  quarters,  un- 
healthful  recreations  and  worry,  nobody  would  deny.  Nor  would  they 
deny  that  all  of  these  things  affect  the  health,  but  it  would  never  be 
possible  to  say  with  certainty  that  an  anaemic,  emaciated  woman,  with 
indigestion,  constipation,  neuralgia  and  sleeplessness  is  suffering  from  an 
occupational  disease  because  she  is  working  for  less  than  a  living  wage. 

Therefore,  we  can  never  make  the  term  occupational  diseases  cover 
more  than  a  small  fraction  of  those  that  are  really  set  up  or  influenced 
by  occupation.  We  can  venture  to  include  under  this  head  only  those 
that  are  caused  by  poisons,  by  very  injurious  kinds  of  dust,  by  extremes 
of  heat  and  cold,  by  sudden  excessive  exertion  resulting  in  acute  dilation 
of  the  heart  by  infection  with  anthrax  or  sometimes  hookworm  and  by 
compressed  air.  There  will  have  to  be  a  great  deal  more  intensive  in- 
vestigation in  this  field  before  we  can  bring  under  this  head  other  causes 
o'f  disease  which  we  know  to  be  affective  but  of  whose  affectiveness  we 
have  not  yet  sufficient  proof. 

Even  the  cases  of  occupational  disease  which  would  come  under  the 
list  given  are  not  by  any  means  all  diagnosed  as  occupational  In  the 
State  of  Illinois  a  law  known  as  the  "Occupational  Disease  Law"  came 
into  effect  July  1,  1912.  This  law  requires  physicians  to  be  employed  in 
establishments  smelting  lead  and  zinc,  manufacturing  or  handling  lead 
compounds,  brass  and  compounds  of  arsenic  or  in  which  poisonous  chem- 
icals, minerals  or  other  substances  are  used  or  handled.  These  phy- 
sicians must  make  physical  examination  of  the  workmen  once  a  month 
and  report  monthly  to  the  Factory  Inspection  Department  the  cases  of 
occupational  disease  which  they  discover.  The  law  was  one  of  the  first 
of  its  kind  passed  in  the  United  States  and  represented  a  decided  step 
forward,  but  is  very  imperfect;  it  does  not  enumerate  nearly  all  the  oc- 
cupational poisons  and,  as  pointed  out  by  the  Department,  it  does  not 
cover  workmen  such  as  journeyman  painters  and  plumbers  who  do  not 
work  in  factories  and  are  not  examined  or  reported  on.  Xor  does  it  apply 
to  physicians  who  are  not  attached  to  manufacturing  plants  and  who  yet 
may  see  many  cases  of  poisoning  from  these  plants.  There  should  be 
compulsory  reporting  of  all  industrial  diseases  by  all  physicians  and 
hospitals. 

Probably  the  law  works  as  well  in  the  lead  industries  as  can  be  ex- 
pected, and  yet  it  would  be  a  great  mistake  to  think  that  the  number  of 
cases  of  poisoning  reported  to  the  department  represent  the  actual  num- 
ber of  those  poisoned  with  lead  in  any  one  industry.  For  various  reasons, 
physicians  employed  by  manufacturing  estahlishments  often  report  only 
a  small  proportion  of  the  cases  that  occur  in  the  plant,  as  has  been  pointed 
out  in  a  Federal  inquiry.^ 

The  working  of  the  Illinois  law,  therefore,  does  not  result  in  records 
of  occupational  poisoning  that  are  complete.  The  requirements  to  re- 
port cases  should  apply  to  all  physicians.  But  in  addition  to  this  some 
check  would  have  to  be  applied  to  the  company  doctors.  It  would  be 
well  if  physicians  connected  with  the  State  Factory  Inspector's  office 

1  BULLETIN  141,  U.  S.  Bureau  of  Labor  Statistics,  p.  79. 


367 


could,  at  certain  intervals,  go  through  the  plants,  examine  the  men  and 
check  up  the  company  doctor^s  reports. 

LEAD  POISONING. 

This  is  universally  considered  the  most  important  of  the  industrial 
poisons.  The  Illinois  Commission  on  Occupational  Diseases  made  a 
necessarily  incomplete  study  of  the  lead  trades  in  the  State  during  the 
year  1910,  and  found  that  lead  poisoning  had  occurred  in  no  less  than  70 
occupations.  Three  hundred  and  eight  cases  of  lead  poisoning  were 
found  to  have  occurred  during  1910,  but  this  figure  was  known  to  repre- 
sent only  a  small  fraction  of  the  real  number.  The  records  of  the 
Factory  Inspection  Department  following  the  passage  of  the  law  con- 
cerning examination  and  reporting,  show  a  gratifying  reduction  from 
year  to  year  in  the  number  of  cases. 


Year. 

Firms 
reporting. ' 

Average 

nvimber 

employees. 

Number 
cases. 

Per  cent 
of  cases. 

1912-3 , . . . . 

H'^''     40 
135 

H       257 
135 
150 

1,880 
5,320 
5,675 
5,492 
6,150 

172 
355 
189 
138 
149 

9.15 

1913-4 

6.67 

1914-5 

3.33 

1915-6 

2.51 

1916-7 

2.40 

The  lead  industries  reporting  under  this  law  are  the  smelting  of 
lead,  refining  lead,  the  manufacture  of  leaden  machine  parts,  wire,  pip- 
ing, sheet  lead,  making  solder  and  babbitt,  lead  tempering,  lead  burn- 
ing, making  car  seals  and  bearings,  making  tinware,  lithotransfer  work, 
the  coiToding  of  white  lead,  grinding  paint,  roasting  oxides,  making  stor- 
age batteries,  making  and  using  lead  enamels.  From  the  factory  in- 
spection reports  it  is  evident  that  the  lead  trades,  well  known  to  be 
dangerous,  such  as  smelting  and  refining,  making  white  lead,  roasting 
oxides  and  making  storage  batteries,  have  been  rendered  much  safer 
than  the  relatively  harmless  trades,  such  as  making  car  seals  and  bearings 
and  making  tin  cans.  In  1913-14  four  can-making  establishments  re- 
ported no  less  than  184  cases  (the  sum  of  cases  reported  in  twelve 
months)  of  lead  poisoning,  although  the  combined  payrolls  numbered 
only  123.  Vigorous  efforts  on  the  part  of  the  Factory  Inspection  Depart- 
ment reduced  this  number  to  10  in  1916-17,  though  the  number  of  em- 
ployees was  then  almost  300.  This  industry,  it  must  be  remembered,  is 
not  inherently  dangerous,  for  the  lead  that  is  used  in  soldering  is  not 
raised  to  a  great  heat  and  is  not  nearly  as  poisonous  as  are  the  compounds 
used  in  other  industries.  Large  numbers  of  women  are  employed  in 
soldering. 

Illinois  has  two  dangerous  lead  trades  not  found  in  every  state, 
the  making  of  lithotransfer  paper  for  decorating  pottery,  and  the 
enamelling  of  sanitary  ware.  The  former  involves  exposure  to  very 
finely  ground  lead  colors,  employs  girls  chiefly  and  has  always  had  a 
fairly  high  rate  of  lead  poisoning.  The  latter  employ  men  who  scatter 
a  finely  ground  glass  enamel  containing  soluble  lead  over  the  red  hot 


368 

surface  of  the  bath  tub  or  sink.  In  1911  an  examination  of  148  enamel- 
lers  showed  that  54,  or  36  per  cent  had  chronic  lead  poisoning  and  38 
men  had  highly  suspicious  symptoms.^  This  industry  reported  no  cases 
of  lead  poisoning  in  1916-17,"  but  there  is  reason  to  believe  that  it  is 
still  prevalent  among  enamellers. 

The  painters'  trade  is  not  covered  by  the  Occupational  Disease  Law 
except  when  it  is  carried  on  in  a  factory,  and,  for  the  most  part,  the 
painting  done  in  factories  involves  less  danger  of  lead  poisoning  than  the 
work  of  the  journeyman  painter.  It  is  true  that  a  good  deal  of  lead  is 
used  in  the  painting  of  carriage  and  automobile  wheels,  and  on  the 
bodies  of  the  more  expensive  vehicles,  and  also  in  the  interior  of 
passenger  cars,  but  machine  painting  is  taking  the  place  of  hand  work 
to  a  great  extent  and  leadless  paints  are  very  largely  used.  Furniture, 
picture  frames  and  mouldings,  agricultural  implements,  farm  wagons, 
are  painted  with  leadless  paint,  and  are  usually  dipped  in  tanks  of  paint. 
All  of  this  work  comes  under  the  law. 

It  would  be  impossible  to  discover  how  much  lead  poisoning  1?here  is 
among  the  28,000  journeymen  painters,  but  we  have  records  of  two  in- 
tensive examinations  of  small  groups.  Dr.  E.  E.  Hayhurst,  of  the 
Illinois  Commission,  now  of  the  Ohio  State  Board  of  Health,  examined 
100  working  painters  in  Chicago  in  1913.  He  did  not  find  symptoms  of 
acute  lead  poisoning  in  any  case,  but  chronic  lead  poisoning  was  evident 
in  59  cases.^  If  the  same  proportion  holds  good  throughout  the  trade, 
16,520  Illinois  painters  have  their  health  more  or  less  seriously  impaired 
as  a  result  of  their  work.  In  1915  the  physicians  of  the  Factory  In- 
spection Department  examined  150  painters  and  found  that  23  had  had 
lead  colic,  26  had  active  pulmonary  tuberculosis  and  10  more  had  it  in 
an  early  or  latent  form,  49  had  hypertrophied  heart,  9  of  these  with 
valvular  trouble,  22  had  chronic  nephritis  and  25  rheumatism.  This  is 
the  record  of  a  very  unhealthful  trade,  if  we  can  assume,  and  there  seems 
to  be  no  reason  why  we  should  not,  that  these  two  groups  represent  the 
average  journeymen  painters  in  the  State.  In  addition  to  the  lead  which 
painters  handle,  they  are  exposed  to  other  poisons  when  they  use  quick 
drying  paints  or  paint  removers,  or  varnishes,  which  are  likely  to  con- 
tain wood  alcohol,  benzol,  carbon  tetrachloride,  and  naphtha.  Turpentine 
is  also  a  poison  to  which  painters  are  exposed,  and  they  suffer  besides 
from  cold  and  dampness  when  working  in  new  buildings,  and  some- 
times from  the  carbon  monoxide  gas  which  is  generated  by  the  salaman- 
ders, that  is,  the  small  charcoal  burners  used  to  dry  the  walls  of  new 
buildings. 

The  amount  of  disability  caused  by  an  attack  of  lead  poisoning  may 
be  great,  or  it  may  be  fairly  slight.  Just  how  much  disability  and  eco- 
nomic loss  is  involved,  loss  of  wages  during  illness  and  earning  capacity 
after  recovery,  it  is  hard  to  say.  Acute  lead  poisoning  usually  seems  to 
mean  a  sojourn  of  five  to  fifteen  days  in  a  hospital,  after  which  the 
patient  is  discharged  "cured."  However,  this  does  not  always  mean  that 
the  man  is  well  enough  to  go  back  to  work.     Even  in  mild  cases  it  may 

2  BULLETIN  104,  U.  S.  Bureau  of  Labor  Statistics,  p.  61. 
*  BULLETIN  120,  U.  S.  Bureau  of  Labor  Statistics,  p.  51. 


369 

be  a  month  before  he  has  recovered  his  strength,  and  many  cases  are  not 
mild.  If  his  attack  has  been  accompanied  by  anaemia,  great  weakness 
or  partial  paralysis,  or  if  there  is  marked  paralysis  and  involvement  of 
the  brain,  kidneys,  blood  vessels  and  heart,  he  may  never  completely 
recover  and  he  will  certainly  be  incapacitated  for  months  at  the  best.  In 
one  lead  smelter  in  1913  as  many  as  30  per  cent  of  the  cases  of  lead 
poisoning  were  of  this  character.  Fifty-three  per  cent  of  the  cases  of 
plumbism  in  American  potters  (men)  were  at  least  moderately  severe, 
and  60  per  cent  of  the  sanitaiy  ware  enamellers  who  were  poisoned 
suffered  from  organic  or  nervous  symptoms.* 

But  it  is  among  painters,  who  are  likely  to  remain  long  at  their 
trade,  that  one  finds  the  largest  proportion  of  cases  of  serious  plumbism. 
A  study  of  100  lead  poisoned  painters  in  Chicago  showed  that  only  33 
had  had  simple  lead  colic  without  complication,  42  had  had  palsy,  9 
cerebral  lead  poisoning,  11  disturbances  of  vision  and  11  general  harden- 
of  the  arteries.^ 

Even  simple  acute  lead  poisoning,  uncomplicated,  may  be  slow  to 
clear  up.  For  instance,  the  records  of  12  lead  poisoned  pasters  in  a 
storage  battery  factor}^,  were  traced  for  a  year  after  their  illness.  These 
men  had  only  been  employed  in  pasting  for  two  to  eight  months.  Two 
of  them  had  recovered  from  their  lead  poisoning  at  the  end  of  three 
weeks^  time ;  one  at  the  end  of  four  weeks,  but  the  remaining  eight  were 
in  poor  health  for  periods  running  from  five  weeks  to  four  months.^ 

OTHER   OCCUPATIONAL   POISONS. 

Zinc  and  brass. — Establishments  making  and  handling  brass  come 
under  the  Occupational  Disease  Law,  but  only  a  few  cases  of  occupational 
sickness  are  reported  from  them.  The  typical  form  of  brass  poisoning 
is  hardly  ever  seen  by  a  physician,  for  it  lasts  only  a  short  time,  the 
men  are  familiar  with  its  symptoms,  know  that  it  will  pass  over,  and  do 
not  send  for  a  doctor.  The  vapors  given  off  in  pouring  brass  contain 
sublimed  oxide  of  zinc,  and  a  workman  who  breathes  these  fumes  may  be 
seized  with  an  attack  of  what  is  called  brass-founder's  ague.  It  usually 
comes  on  some  hours  after  work  and  consists  in  a  feeling  of  weakness, 
languor,  loss  of  appetite,  and  nausea,  a  condition  much  like  sea-sickness. 
Then  there  is  a  violent  chill  lasting  about  an  hour,  the  throat  is  parched, 
there  are  pains  and  cramps  in  the  muscles  of  the  legs  and  a  feeling  of 
deathly  sickness.  The  chill  is  followed  by  profuse  perspiration  and  relief 
from  pain,  but  prostration  which  lasts  several  hours,  and  there  may  be 
some  fever  during  this  stage.  The  next  morning  the  man  may  feel  weak 
and  have  a  loathing  for  food,  but  he  usually  reports  for  work. 

The  same  sickness  is  found  among  zinc  smelters  and  founders  and 
is  known  as  "smelter  shakes."  Occasionally  cases  occur  in  welding 
zinc  by  the  oxyacetyline  flame.  About  70  to  80  per  cent  of  brass  and 
zinc  workers  are  susceptible  to  this  form  of  poisoning,  but  it  occurs  only 
when  the  zinc  is  volatilized  by  heat.  Workers  with  the  solid  metals  are 
never  affected  in  this  way.     What  is  often  reported  as  brass  poisoning 

*  BULLETIN  104,  U.  S.  Bureau  of  Labor  Statistics,  pp.  56-64. 
"BULLETIN  120,  U.  S.  Bureau  of  Labor  Statistics,  p.  58. 
•bulletin  165,  U.  S.  Bureau  of  Labor  Statistics,  p.  26. 

—24  H  I 


4 


370 

among  brass  polishers  and  buffers  is  really  lead  poisoning,  for  brass, 
which  is  an  alloy  of  copper  and  zinc,  often  contains  a.  small  proportion  of 

lead. 

Lead  poisoning  has  increased  during  the  past  year  in  Illinois  zinc 
smelting  because  of  the  use  of  Australian  ore  which  formerly  was  sent 
to  Germany  and  which  contains  7  or  8  per  cent. of  lead. 

The  brass  industry  is  not  in  any  country  considered  as  healthful  as 
the  average  occupation.  Hayhurst,  who  investigated  brass  founding  in 
Illinois  for  the  Occupational  Disease  Commission,  interviewed  187  brass 
founders  and  obtained  from  146  a  history  of  illness  which  he  attributed 
to  their  occupation.  He  found  only  17  men  oyer  fifty  years  of  age  among 
1,761  brass  foundrymen  in  the  city  of  Chicago.'^ 

Arsenic. — Arsenic  is  not  an  important  poison  in  Illinois.  There 
are  a  few  factories  manufacturing  or  handling  the  insecticides,  Paris 
green  and  arsenate  of  lead.  Thirteen  cases  of  poisoning  from  arsenic 
were  reported  in  1913-14.  Other  sources  of  arsenical  poisoning  are  the 
trades  in  which  the  heavy  acids,  nitris,  muriatic,  sulphuric,  come  in  con- 
tact with  iron  or  zinc,  for  metal  and  acid  may  both  contain  arsenic  as 
an  impurity.  For  instance,  it  is  well  known  that  lead  burners,  who  use  an 
oxyhydrogen  flame  may  get  arsenical  poisoning  because  the  hydrogen 
is  produced  by  the  action  of  muriatic  acid  on  zinc.  Makers  of  toy 
balloons  that  are  filled  with  hydrogen  may  become  poisoned  in  the  same 
way. 

Antimony. — Antimony  is  used  in  type  metal  up  to  about  20  per 
cent,  the  harder  the  metal  the  greater  the  amount  of  antimony.  The 
sulphides  usually  called  "sulphurated  antimony,^'  are  used  to  color 
rubber  a  red  brown.  In  neither  of  these  industries  is  antimonial  poison- 
ing of  any  consequence. 

Phosphorus. — The  phosphorous  poisoning  of  match  makers  is  now 
a  thing  of  the  past  and  need  not  be  entered  on  here.  "  White  phosphorous 
is  used  in  the  manufacture  of  certain  explosives  and  fire  works,  but  not 
so  far  as  we  know  in  Illinois.  Mercury  is  used  in  the  form  of  the  nitrate 
in  the  manufacture  of  felt  hats,  and  as  a  metal  in  the  making  of 
thermometers  and  vacuum  pumps,  but  these  are  not  important  industries 
in  Illinois. 

Miscellaneous  poisonous  gases. — Other  industrial  poisons  which,  in 
some  states,  are  the  cause  of  a  great  deal  of  sickness,  are  unimportant  in 
Illinois.  These  are  carbon  disulphide,  a  nerve  poison  used  in  curing 
certain  kinds  of  rubber;  carbon  tetrachloride,  used  in  the  same  way; 
chlorine  gas  used  to  make  bleaching  powder  and  given  off  in  the  course 
nitric  acid  manufacture.  Nitrous  fumes,  that  great  danger  in  the  manu- 
facture of  explosives,  are  a  danger  in  one  smokeless  powder  plant  in  Illi- 
nois and,  to  a  slighter  extent,  in  the  plating  of  metals  where  nitric  acid 
is  used  to  prepare  the  metal  for  platting,  and  in  the  making  of  Prussian 
blue  when,  if  the  mass  of  blue  catches  fire,  these  dangerous  fumes  are 
given  off.  Ammonia  gas  has  caused  a  number  of  cases  of  pneumonia, 
some  of  them  fatal,  when  there  has  been  accidental  bursting  of  the  pipes 
in  refrigerating  plants. 

^  Kober  and  Hanson,  Industrial  Diseases,  Philadelphia,  p.  9. 


371 

Carbon  monoxide. — By  far  the  most  important  gas  in  industry  is 
carbon  monoxide,  which  causes  an  increasing  number  of  cases  of  poisoning 
every  year.  This  gas  is  dangerous  in  very  small  quanities,  for  so  little 
as  one  part  in  one  thousand  paj'ts  of  air  will  cause  disturbing  symptoms, 
while  two  to  three  parts  constitute  a  dangerous  amount.  The  Factory 
Inspection  Department  of  Illinois  reports  for  1915-16  seventeen  severe 
cases  of  carbon  monoxide  poisoning,  with  seven  deaths.  An  enormous 
number  of  workmen  are  exposed  at  times  to  these  fumes  in  the  course  of 
their  work,  for  they  are  given  off  whenever  complete  combustion  is  inter- 
fered with,  or  when  there  is  leakage  from  chimneys,  pipes  and  mains. 
Cases  are  reported  from  the  blast  furnaces  in  steel  works;  from  ore 
smelters ;  metallurgical  plants ;  foundries ;  coke  by  products  works ;  brick 
kilns;  enamelling  furnaces;  bakeries;  laundries;  steam  power  plants, 
in  fact,  any  place  in  which  producer  gas  is  used  for  heat  or  power. 
An  increasingly  large  number  of  cases  occurs  in  the  automobile  industry, 
from  the  testing  department,  for  the  exhaust  gases  from  motor  cars  con- 
tain a  large  percentage  of  carbon  monoxide.  Leaking  gas  mains  are  the 
cause  of  poisoning  of  electrical  conduit  workers,  sewer  repair  men,  and 
men  repairing  gas  mains. 

This  is  acute  carbon  monoxide  poisoning.  Usually  the  man  has 
warning  symptoms,  pressure  and  throbbing  in  the  temples,  roaring  in 
the  ears,  a  "ca\4ng-in"  at  the  knees,  but  sometimes  he  drops  unconscious 
to  the  ground  without  any  premonitory  sj^mptoms.  Earely  he  dies  with- 
out recovering  consciousness,  usually  he  comes  to,  but  not  completely, 
and,  if  he  recovers,  several  days  may  pass  before  he  is  quite  normal  again. 
He  may  escape  any  lasting  injury  but  a  large  number  of  cases  of  "gas- 
sing'^ from  carbon  monoxide,  especially  during  cold  weather,  develop ' 
pneumonia  shortly  after.  Another  very  distressing  sequence  is  mental 
deterioration,  with  various  nervous  disorders.  There  are  a  number  of 
cases  now  on  record  of  carbon  monoxide  poisoning  followed  by  loss  of 
memory,  inability  to  find  one's  way  about,  loss  of  desire  to  work  and  of 
ability  to  follow  out  a  mental  process.  This  condition  may  persist  for 
months,  and  probably  it  may  be  permanent,  although  most  of  the  cases 
are  still  too  recent  for  this  point  to  be  determined. 

Chronic  carbon  monoxide  poisoning  is  probably  much  more  common 
than  the  acute,  but  is  not  nearly  so  well  recognized.  This  is  found 
among  people  who  work  in  rooms  with  naked  gas  jets,  unless  there  is 
abundant  natural  ventilation,  or  a  system  of  exhaust  pipes  to  carry  off 
the  gas  fumes.  Linotypists,  electrot3'pers,  stereotypers,  monotype  casters, 
solderers  in  Canneries  and  other  places,  pressers  in  tailor  shops,  men  em- 
ployed in  making  metal  castings,  all  these  may  be  exposed  to  slow  poison- 
ing with  carbon  monoxide  if,  as  is  usually  the  case,  heat  is  supplied  by 
naked  gas  jets.  The  symptoms  of  such  poisoning  are  dullness  and  lassi- 
tude, headache,  inability  to  concentrate  the  mind,  loss  of  appetite,  poor 
nutrition,  loss  of  weight,  neurasthenic  disorders.  The  condition  under- 
lying these  symptoms  is  poverty  of  the  blood,  a  pronounced  loss  of  red 
blood  corpuscles.  The  amount  of  ill-health  and  lessened  working  capac- 
ity, and  predisposition  to  infectious  diseases  that  is  caused  by  chronic 


372 

carbon  monoxide  poisoning,  has  never  been  estimated,  but  it  is  probably 
large. 

Among  the  men  exposed  to  carbon  monoxide  gas  in  the  steel  mills 
the  investigators  for  the  Illinois  Occupational  Disease  Commission  found 
a  deficient  muscular  power.  The  investigators  used  the  hand  dynamo- 
meter and  obtained  the  following  results  after  examining  400  men. 
They  compared  Avith  the  men  exposed  to  carbon  monoxide  gas  another 
group  employed  in  the  same  steel  works,  but  not  at  occupations  which 
exposed  them  to  gas.  This  table  shows  the  comparison  of  the  muscular 
strength  of  the  hand  of  those  of  the  two  groups. 


Ages  20-40. 


Ages  over 
40. 


Workers  not  exposed  to  carbon  monoxide,  average  strength. 
Workers  exposed  to  carbon  monoxide,  average  strength 


134. 43 
117. 13 


113. 01 
94.3 


The  Occupational  Disease  Commission  in  its  report  stated  that  is  is 
important  to  determine  whether  the  loss  of  power  noted  is  due  to  carbon 
monoxide. 

Coal  tar  products: — Of  late  years  a  new  class  of  occupational  poisons 
has  appeared  in  American  industry  and  is  taking  an  important  place. 
These  are  the  coal  tar  products,  benzol,  nitrobenzols,  toluol,  nitrotoluols 
and  a  great  variety  of  products  derived  from  these,  the  most  important 
of  which  is  aniline.  These  are  poisons  which  act  on  the  blood  and  the 
central  nervous  system,  producing  alarming  symptoms  in  acute  cases, 
'vague  and  not  easily  recognizable  symptoms  in  chronic  cases.  None  of 
them  so  far  is  of  as  great  importance  in  Illinois  as  in  some  of  the  other 
large  manufacturing  states,  but  their  use  is  increasing  all  the  time.  Ben- 
zol is  largely  taking  the  place  of  the  less  harmful  petroleum  derivatives, 
gasoline,  naphtha,  and  benzine.  It  is  used  in  large  quantities  in  rubber 
manufacture,  in  one  method  of  sealing  cans,  in  the  rubber  cement  used 
for  making  straw  hats,  in  type  and  roller  cleaners,  to  some  extent  in  dry 
cleaning  establishments.  Because  benzol  is  now  recovered  in  coke  by- 
products works  a  new  danger  has  been  added  to  this  particular  industry. 
Aniline  is  used  in  compounding  rubber,  in  type  and  roller  cleaners  and, 
in  one  plant,  in  the  making  of  aniline  dyes.  Toluol  is  recovered  from 
coal  tar  in  gas  works.  Its  most  important  compound,  trinitrotoluol,  or 
T.  N.  T.,  is  not  manufactured  in  this  State. 

Wood  alcohol  was  first  recognized  as  an  important  industrial  poison 
in  1906  when,  in  hearings  before  the  Ways  and  Means  Committee  of 
Congress  on  removing  the  revenue  tax  from  denatured  alcohol,  the  hat- 
workers'  union  presented  affidavits  from  75  felt  hat  makers  who  had 
suffered  impairment  to  health  or  sight  from  using  shellac  made  with  wood 
alcohol.  Since  then  it  has  been  recognized  that  wood  alcohol  may  be 
absorbed  through  the  skin  or  through  breathing  fumes,  and  that  it  may 
cause,  not  only  serious  gastric  and  nervous  symptoms,  but  partial  or 
even  total  blindness.  The  largest  number  of  severe  cases  have  occurred 
in  the  varnishing  of  the  interior  of  brewery  vats.     Cases  have  also  oc- 


373 

curred  in  many  industries  where  varnish  is  used  or  removed.  It  is  also 
an  ingredient  of  paint  removers.  It  is  used  by  electrotypers  and  photo- 
engravers,  in  dyeing  artificial  flowers  and  feathers,  in  making  shoe  polish 
and  in  manufacturing  celluloid  and  aniline  dyes.  The  Factory  In- 
spectoi*^s  report  for  1915-16  mentions  five  cases  of  wood  alcohol  poisoning 
contracted  in  cabinet  finishing  and  in  painting. 

DISEASES   CAUSED  BY  PHYSICAL  AGENTS. 

This  is  a  very  incomplete  list  of  the  industrial  poisons  used  in  Illi- 
nois, but  it  comprises  the  most  important  ones.  Even  if  the  list  were 
complete  and  if  we  were  able  to  say  exactly  how  many  workers  had  suf- 
fered from  each  form  of  poisoning  we  should  have  only  a  small  percentage 
of  the  sickness  in  this  State  that  is  wholly  or  partically  occupational  in 
character.  We  should  have  to  add  to  it  the  injury  to  health  caused  by 
exposure  to  excessive  heat  in  foundries,  to  heat  and  humidity  in  bakeries, 
kitchens,  canneries  and  laundries,  and  to  damp  cold  in  the  pickling  and 
salting  departments  in  meat  packing  plants.  Repeated  efforts  requir- 
ing over-strain  may  result  in  gradual  or  sudden  dilatation  of  the  heart 
with  leaking  valves.  In  the  early  days  of  the  war  the  Germans  found 
that  the  men  who  developed  sudden  acute  heart  failure  after  forced  ex- 
ertion were  chiefly  the  ones  who,  in  civil  life,  had  done  very  heavy  manual 
work. 

Caisson  disease  is  undeniably  occupational  in  origin,  for  it  follows 
exposure  to  compressed  air.  It  occurs  among  divers  and  men  working 
in  construction  work  under  water,  where  compressed  air  is  used  to  keep 
out  water  and  prevent  the  walls  from  caving-in.  The  workman  in  a 
caisson  experiences  little  trouble  on  entering  the  compartment  filled  with 
compressed  air  or  while  he  is  at  work  there,  except  possibly  pain  in  his 
ears  from  pressure  on  the  drums,  but  when  he  returns  to  the  ordinary 
atmosphere,  he  runs  great  risk  of  trouble  unless  the  transition  is  made 
slowly  and  gradually.  The  compression  has  increased  the  amount  of 
air  held  in  the  blood  and  tissues  and  when  the  pressure  is  removed,  gas. 
mainly  nitrogen,  is  released  in  the  form  of  bubbles  in  the  blood  and 
tissues,  and  the  mechanical  pressure  of  these  bubbles  in  a  delicate  tissue 
like  the  spinal  cord  or  the  retina  of  the  eyes  may  cause  more  or  less 
serious  injury,  even  death.  Bassoe  found  161  men  with  a  history  of 
caisson  disease  and  six  deaths  which  had  occurred  during  1909  in 
Illinois.  The  men  were  working  chiefly  in  the  construction  of  tunnels 
for  water  and  freight,  constructing  sewers,  building  bridges,  and  more 
rarely,  laying  the  foundations  of  buildings.^ 

The  symptoms  of  caisson  disease  usually  come  on  within  an  hour 
after  returning  to  the  ordinary  air.  There  are  severe  pains  in  the  legs 
and  lumbar  region,  known  as  "the  bends '/'  more  rarely,  dizziness  known 
as  the  "staggers,"  and  sometimes  great  difficulty  in  breathing,  known  as 
"the  chokes."  Among  the  161  cases  examined  by  Dr.  Bassoe  were  some 
who  had  experienced  the  severe  s}Tnptoms  years  before,  but  had  been 
left  with  permanent  impairment  of  health.  Three  had  some  form  of 
paralysis,  12  symptoms  of  disease  of  the  spinal  cord,  11  stifl'ness  and  pain 

'  Illinois  Commission  on  Occupational  Disease,  Report,  p.  127. 


374 

in  bones  and  joints,  and  65  impaired  hearing.     Caisson  disease  is  not 
reportable  in  Illinois. 

DUSTY  TRADES.  ^ 

It  is  impossible  in  the  space  of  this  summat^  statement  to  do  more 
than  mention  the  dusty  diseases,  pulmonary  tuberculosis,  fibroid  phthisis, 
and  pneumonia.  Undoubtedly  these  are  much  more  numerous  than  any 
other  class  of  industrial  diseases,  but  the  occupational  element,  though 
long  recognized  by  physicians^  is  necessarily  less  clear  than  in  the  case  of  ; 
those  diseases  resulting  from  poisons.  What  follows  is  a  very  brief  state- 
ment of  the  chief  facts  concerning  sickness  in  the  dusty  trades.  According 
to  an  estimate  made  by  Frederick  Hofftnan^  of  the  Prudental  Life  Insur- 
ance Company,  it  appears  that  of  the  44,130,000  men  and  women 
wage-earners  in  America,  9.06  per  cent  work  under  conditions  more  or 
less  detrimental  to  health  because  of  the  presence  in  the  atmosphere  while 
they  are  at  work  of  various  dusts  which  predispose  to  some  form  of  pul- 
monary disease,  or  render  more  serious  any  disease  of  the  respiratory 
tract.^ 

These  are  the  workers  exposed  to  metallic  dust,  mineral  dust,  vege- 
table fibres  and  dust,  animal  dust  and  mixed  dusts.  The  different  . 
varieties  differ  in  their  effects,  but  all  produce  some  effect  on  the  respira- 
tory tract.  If  their  action  is  mechanically  irritating,  tuberculosis  or 
acute  pneumonia  is  likely  to  result.  Such  irritating  dusts  are  the 
metallic  dust  from  knife-grinding  and  metal  polishing;  the  dust  from 
the  harder  varieties  of  stone,  especially  flint  and  granite  and  carbor- 
undum; sharp  bits  from  straw,  jute,  burlap^  linen  and  cotton,  fur  and 
hair,  and  also  mixed  metal  and  stone,  such  as  is  produced  in  wet  grinding 
of  agricultural  implements  when  the  air  grows  foggy  with  tiny  droplets 
carr}dng  sandstone  dust  and  particles  of  steel.  Another  occupation 
which  involves  exposure  to  very  injurious  dust  is  sand-blasting  metal  to 
prepare  it  for  painting,  plating  or  enamelling.  Very  firm  sand  is  driven 
with  great  force  against  the  metal  surface  and  the  particles  rebound, 
filling  the  air.  It  is  important  to  remember  that  the  dust  that  does  the 
real  injury  must  be  very  fine,  for  coarser  particles  do  not  reach  the 
lungs. 

If  the  effect  of  the  dust  is  only  mildly  irritating,  the  tuberculosis 
rate  will  not  be  high,  but  there  may  be  a  very  high  death  rate  from 
pneumonia,  and  there  may  be  a  great  deal  of  asthma.  The  softer,  more 
easily  diffused  dust,  of  which  coal  dust  is  the  best-known  instance,  does 
not  directly  injure  the  lungs,  but  by  its  pressure  it  sets  up  a  slow  process 
of  hardening  in  the  tissues,  a  condition  known  usually  as  "miner^s  con- 
sumption" or  fibroid  phthisis.  Sometimes  a  tuberculous  infection  may 
develop  upon  this  process,  but  more  often  the  man  dies  of  a  lobar  pneu- 
monia, because  the  hardening  of  the  tissue  has  made  it  impossible  for  the 
lung  to  get  rid  of  the  inflammatory  process  and  the  pneumonia  cannot 
clear  up  as  it  could  in  a  normal  lung. 

If  dust  is  poisonous  as  well  as  mechanically  irritating,  its  harm- 
fulness  is  greatly  increased.     An  instance  of  this  combined  effect  is  seen 

"BULLETIN  231,  U.  S.  Bureau  of  Labor  Statistics,  p.  12. 


375 

in  the  hatter^s  trade.  The  fine  hairs  from  the  rabbits'  fur  \vhich  has  been 
treated  with  nitrate  of  mercury  render'  this  trade  one  of  the  most  un- 
healthful  of  modern  industries,  with  a  high  tuberculosis  rate.  All  lead 
dust,  also,  has  this  double  effect,  and  it  is  notorious  that  lead  and  tubercu- 
losis go  hand  in  hand.^"  « 

The  harmfulness  of  a  dusty  trade  does  not  depend  on  the  character 
of  the  dust  alone ;  it  depends  also  on  the  surroundings  of  the  workers  and 
on  their  own  powers  of  resistance.  A  dusty  process  carried  on  out  of 
doors  is  far  less  harmful  than  the  same  sort  of  work  done  indoors.  This 
has  been  recognized  by  the  Granite  Cutters'  Union,  which  has  insisted 
on  having  the  mechanical  surfacers  that  grind  the  surface  of  the  stone 
moved  from  the  shed  to  the  outside,  and  by  the  sandblasters  of  steel  cars 
at  an  Illinois  plant,  who  now  do  all  their  work  in  the  open  air.  If  the 
dusty  work  is  cari'ied  on  indoors  the  harmfulness  is  increased  by  heat 
and  humidity,  because  these  lower  the  resistance  of  the  worker. 

The  Illinois  factory  inspectors  recognize  as  dusty  trades  the  follow- 
ing: metal  polishing,  coal  mining,  cigar  making,  stone  cutting,  glass 
manufacture,  cement  Avorking,  the  bakers'  trade,  working  in  jute  flax, 
textile  establishments,  porcelain  manufacture,  polishing  mother  of  pearl. 

The  connection  between  occupation  and  disease  is  still  imperfectly 
L-nderstood,  although  each  year  adds  to  our  knowledge  of  the  importance 
of  industrial  prosesses  and  industrial  surroundings  on  the  health  of  the 
workers.  The  effects  of  dangerous  work  are  really  now  in  a  fair  way  to 
be  generally  recognized,  the  effects  of  ordinary  work — such  as  are  pro- 
duced by  faulty  lighting,  jarring  noise,  too  great  humidity,  stagnant  air, 
cramped  posture,  dusts  that  are  almost  imperceptible,  and  other  factors 
which  slowly  undermine  health — these  are  not  yet  generally  recognized. 
Et  is  safe  to  say  that  the  greater  part  of  industrial  sickness,  of  which  in- 
dustry is  either  an  exciting  or  a  contributary  cause  is  not  yet  recognized 
as  industrial  nor  provided  for  by  law. 

^"  Elnamelling  sanitary  ware  is  a  striking  example.  The  men  scatter  a  finely 
grround  glaze,  containing  soluble  lead  over  red  hot  metal.  Sharp  dust  particles,  lead, 
and  excessive  heat  combine  to  make  a  very  dangerous  industry. 


376 


SPECIAL  REPORT  V.     HEALTH  OF  ILLINOIS  COAL 

MINERS. 

(Abstract  of  a  Report  by  Emery  R.  HayJiurst,  Ph.  D.,  M.  D.) 


In  1915  only  Pennsylvania  and  West  Virginia  ranked  above  Illinois 
as  producers  of  coal.  With  51,  or  half  of  the  counties  contributing,  her 
total  production  for  the  fiscal  year  ending  June  30,  1917,  was  78,983,527 
tons.  The  total  number  of  persons  employed  in  the  mines  during  the 
first  six  months  of  1918  was  in  excess  of  90,000. 

Though  certain  features  of  ventilation^  temperature  and  humidity, 
and  especially  explosions  and  sudden  disasters  such  as  asphyxia,  in  coal 
mining  have  been  investigated  by  the  United  States  Bureau  of  Mines,  state 
mining  departments,  and  associated  institutions,  comparatively  little  has 
been  done  to  ascertain  the  health  hazards  of  bituminous  coal  miners.  In 
the  survey  made  by  the  Illinois  Commission  on  Occupational  Diseases  in 
1910,  nystagmus  alone  was  investigated.  Because  of  the  importance  of  the 
industry  in  this  State  and  the  limited  knowledge  of  the  conditions  affect- 
ing the  health  of  those  engaged  in  it,  the  Commission  employed  Dr. 
Emery  R.  Hayhurst,  Ph.  D.,  M.  D.,  Assistant  Professor  of  Hygiene, 
Ohio  State  University,  to  make  an  investigation  of  the  health  of  Illinois 
coal  miners.  Dt.  Hayhurst  brought  to  this  research  a  valuable  ex- 
perience gained  in  a  like  invesigation  in  his  own  state.  Somewhat 
earlier,  in  1913-14,  he  had  investigated  industrial  health  hazards  and 
occupational  diseases  in  Ohio  for  the  State  Board  of  Health,  the  results 
of  which  were  published  in  a  well-known  report.  In  his  investigation 
in  Illinois,  and  especially  in  the  survey  of  housing  conditions  and  local 
health'  administration.  Dr. Hayhurst  was  ably  assisted  by  Mr.  Paul  L. 
Skoog,  Director  of  Surveys  of  the  Department  of  Health  of  this  State. 
The  investigation  has,  therefore,  been  a  joint  one  for  the  Department  of 
Health  and  the  Health  Insurance  Commission. 

The  extent  and  nature  of  the  investigation'  made  are  set  forth  in  the 
following  abstract  of  the  report  prepared  by  Dr.  Hayhurst.  Unfortun- 
ately, because  of  the  necessity  of  reducing  the  size  of  this  volume,  the 
complete  report  submitted  cannot  be  printed. 

I.   INTRODUCTION. 

In  order  to  obtain  an  accurate  knowledge  of  health  hazeards,  health 
conditions,  and  public  health  administration  in  coal  mining  communities, 
and  to  find  what  provision  is  made  for  meeting  sickness  and  death,  the 
Health  Insurance  Commission  assigned  these  subjects  for  investigation 
to  Mr.  Paul  L.  Skoog,  Director  of  Surv^eys  of  the  State  Department  of 
Health,  and  the  writer.     By  way  of  preparation  for  the  invesigation 


377 

conferences  were  held  with  some  of  the  operators,  with  the  President  of 
District  XII  of  the  United  Mine  Workers,  with  the  Director  and  Assist- 
ant Director  of  the  Department  of  Mines  and  Minerals,  with  Dt.  C.  St. 
Clair  Drake  and  Dr.  George  T.  Palmer,  Director  and  Assistant  Director, 
respectively,  of  the  State  Department  of  Health,  and  with  certain  other 
officials  and  informed  persons.  The  itinerary  for  the  trip  of  investi- 
gation included  representative  centers  in  each  coal  district  of  the  State 
and  each  of  these,  mine  inspectors,  physicians,  mine  managers  and  others 
were  interviewed  and  fifty-six  mines  w^ere  visited  and  examined.  Table 
I  shows  at  a  glance  the  distribution  of  the  sources  of  information. 

TABLE  I— SOURCES  OF  FIELD  INFORMATION. 


District 
number. 


Number 
counties 
com- 
prised. 


Principal  city  or  cities 
in  district. 


Number 

of  miners 

(1917). 


Number 
cotmties 
visited. 


Number 

mines 

visited. 


Number 

of  men  at 

mines 

visited. 


Number 
phys- 
icians 
inter- 

\iewed. 


I 

9 
6 
7 
5 
5 
4 
3 
2 
4 
1 
3 
2 

II 

Ill 

IV 

V 

VI 

VII 

VIII 

IX 

X 

XI 

XII 

Total 

51 

LaSalle 

Peoria 

Canton 

Springfield 

Danville,  Pana 

Hillsboro,  Staunton. 
Centralia,  Edwardsville 

Belleville 

DuQuoin 

Benton 

Eldorado,  Harrisburg.. 
Marion 


7,431 

3 

7 

1,953 

3,772 

4 

6 

993 

3,524 
7,690 
6,859 
9,001 
5,420 

1 
2 
3 
2 
2 

4 
5 
6 
4 
6 

728 
2,042 
1,544 
1,625 
1,813 

6,761 

1 

5 

401 

5,511 
10,511 

3 

1 

3 
2 

590 
1,672 

5,007 

1 

3 

721 

9,306 

1 

5 

1,727 

80,893 

24 

56 

15,809 

5 
6 
2 

10 
4 
5 
3 
4 
2 
3 
4 
5 


53 


In  addition  to  the  above,  mortality  statistics  were  compiled  from 
records  in  the  district  office  of  the  United  Mine  Workers,  and  the  status 
of  sickness  and  death  benefit  associations  was  obtained  from  a  question- 
naire sent  out  by  the  Commission  to  the  various  local  unions  as  well  as  by 
field  inquiry.  The  selection  of  mines  was  made  so  as  to  include  mines 
of  large,  medium  and  small  production  and  those  adjudged  by  inspectors 
or  others  to  be  good,  fair  and  bad  in  respect  to  working  conditions. 
Furthermore,  the  investigation  covered  typical  examples  of  housing 
conditions  and  included  a  study  of  the  various  methods  used  in  mining 
communities  to  cope  with  sickness  and  death.  The  investigators  traveled 
by  automobile  for  a  four  weeks'  period  during  July  and  August,  1918, 
thei  itinerary  covering  24  principal  coal  mining  counties  in  which  54 
cities  and  towns  were  visited. 

• 

The  vast  majority  of  Illinois  coal  miners  (96.09  per  cent)  in  1917 
worked  in  the  324  shipping  or  commercial  mines,  leaving  3.91  per  cent 
who  worked  in  the  486  small  mines  or  those  supplying  the  local  trade. 
The  chief  coal-producing  counties  are,  in  descending  order:  Franklin, 
Williamson,  and  Saline  (southern)  ;  Sangamon,  McCoupin,  Madison 
and  St.  Clair  (central  and  western)  ;  LaSalle,  Bureau,  Fulton,  and 
Peoria  (northern)  ;  and  Vermilion  (eastern). 


378 

II.    WORKING   CONDITIONS    AND   HEALTH. 

The  discussion  of  working  conditions  and  health  must  be  introduced 
by  a  few  more  or  less  technical  details,  and  few  data  relating  to  the  race 

and  age  of  miners. 

The  shaft  type  of  mim  and  room-and-pillar  style  of  development 
are  the  principal  forms  of  mines  in  Illinois.  Long-wall  mining,  in 
which  ventilation  is  a  little  easier  to  maintain,  characterizes  three  or  four 
of  the  northern  counties.  Illinois  is  considered  a  localty  of  deep  mining. 
Mines  in  general  vary  in  depth  from  those  upon  the  surface  which  are 
simplv  stripped,  to  700  feet,  but  one  mine,  at  Assumption,  is  1,004  feet 
deep. "  All  geological  seams  from  Nos.  1  to  7  are  worked,  the  principal 
ones  being  Nos.  6,  5,  and  2  (the  deepest  known  seam  is  designated  "No. 
1'').  The  distance  to  the  working  face  in  older  mines  runs  as  high-  as 
three  miles  from  the  foot  of  the  hoisting  shaft.  The  power  used  for 
hoisting  is  usuallj^  steam,  but  some  large  mines  are  electrically  equipped 
while  smaller  ones,  particularly  drifts,  use  animal  or  man  power.  Haul- 
age in  mines  is  principally  by  electric  motors  with  mules  for  terminal 
work.  The  barns  needed  may  be  located  above  or  below  ground.  Min- 
ing machines  undercut  about  two-thirds  of  the  coal  produced,  the 
balance  being  mined  by  hand.  There  are  a  trifle  over  six  times  (24,951) 
as  many  "miners"  (working  by  hand),  exclusive  of  loaders  (24,529),  as 
there ^  are  men  mining  coal  with  machines  (3,957).  Machine  mining 
has  not  come  into  vogue  so  much  in  Illinois  as  in  Ohio  and  elsewhere. 

The  chief  Hasting  substance  used  is  black  powder,  ranging  in  sizes 
from  26/64ths  (CC)  to  9/64ths  (FF).  In  the  southern  counties  "per- 
missible explosive"  is  used  extensively  while  in  the  long-wall  mines  of 
the  north,  where  the  shooting  down  of  a  rocky  roof  is  necessary,  much 
dynimite  is  used.  The  State  law  requires  that  the  blasting  of  coal  be 
done  outside  of  working  hours,  and,  in  mines  of  a  stated  size,  specially 
trained  men,  called  "shot-firers,"  perform  this  duty.  With  the  ex- 
ception of  mines  under  100  feet  or  so  in  depth  Illinois  mines  are  classed 
as  dry  mines.  They  are  dryer  in  the  winter  than  in  the  summer,  and 
sprinkling  of  roadways  is  a  common  procedure  to  prevent  the  explosion 
of  dust. 

The  chief  mine  gases  are  of  three  types:  fire  damp  (methane,  CH4) 
which  is  explosive  but  not  dangerous  to  health;  black  damp  (where  car- 
bon dioxide  and  nitrogen  are  increased  at  the  expense  of  oxygen)  ;  and 
white  damp  (carbon  monoxide).  The  first  two  "damps"  occur  naturally 
in  mines,  and  artificial  ventilation,  which  is  promoted  as  a  rule  by  means 
of  large  blow  fans,  is  necessary  to  keep  these  gases  sufficiently  diluted 
to  prevent  explosions  and  to  supply  enough  oxygen  to  the  workmen  for 
breathing  purposes  and  for  the  burning  of  lamps.  The  State  mining 
laws  are  very  specific  with  reference  to  this  artificial  ventilation  of  mines 
and  through  the  inspection  system  and  the  employment  of  mine  examiners 
by  the  opei-ators,  a  high  degree  of  success  in  ventilation  is  usually 
obtained.  The  mines  of  the  southern  part  of  the  State  tend  to  produce 
fire  damp  and  many  explosions  occur,  but,  on  the  whole,  mining  men  state 
that  Illinois  mines  are  not  classed  as  particularly  "gassy"  (meaning  fire- 


379 

damp) .  Unlike  many  British  mines  there  is  not  one  in  Illinois  in  which 
safety  lamps  have  to  be  used  exclusively.  White  damp  occurs  in  mines 
in  connection  with  fires  and  explosions  and  the  blasting  of  powder  when 
the  air  supply  is  insufficient.  It  is  always  the  result  of  incomplete  com- 
bustion. It  is  the  dangerous  component  of  "after  damp"  which  occurs 
after  fires,  etc.,  and  which  has  rather  more  effect  on  canaries  or  mice  than 
upon  men  so  that  the  former  have  been  used  as  test  animals.  The  col- 
lections of  this  gas  are  insidious  and  the  miner  has  no  ready  means  of 
detecting  it.  "Feeders"  or  "blowers"  of  illuminating  gas,  such  as  used 
for  domestic  purposes,  are  little  known  in  Illinois.  Gasoline  locomotives, 
from  which  the  dangerous  exhaust  fumes  characteristic  of  gasoline  motors 
occur,  are  used  in  less  than  ton  mines  in  the  State  and  apparently  these  are 
gradually  being  replaced  with  devices  less  dangerous  to  the  atmosphere. 

Miners  usually  work  two  in  a  room,  or  at  least  in  pairs,  in  two  or 
more  rooms,  and  an  especial  feature  of  ventilation  is  to  split  the  air  cur- 
rents entering  the  mine  so  as  to  pass  fresh  air  in  a  method  of  even  dis- 
tribution to  these  work  rooms.  The  law  requires  that  no  men  be  allowed 
to  work  in  rooms  or  advancing  entries  more  than  60  feet  "ahead  of  the 
air,"  which  means  the  distance  from  a  definite  air  current  of  given 
volume.  An  effort  is  made  to  keep  this  air  current  equal  to  100  cubic 
feet  per  man  per  minute  with  a  50  per  cent  increase  in  gassy  mines  and 
a  500  per  cent  increase  for  each  animal. 

The  temperature  of  mines  is  fairly  constant.  Shallow  or  wet  mines 
with  a  temperature  ranging  between  50  and  60  degrees  at  the  working 
face  are  the  coolest.  Mines  from  300  to  600  feet  deep  have  tempera- 
tures ranging  from  60  to  70  degrees,  those  from  600  to  1,000,  tempera- 
tures ranging  from  70  to  80  degrees.  Slight  seasonal  variations  occur. 
The  air  always  increases  in  temperature  on  its  passage  through  the  mine. 
The  humidity  of  mine  air  is  invariably  high  since  even  air  carrying 
minimum  amounts  of  water  vapor  into  the  mine,  as  in  the  winter  time, 
still  leaves  the  mine  nearly  saturated,  for  it  absorbs  moisture  out  of  the 
coal  and  strata.  "The  humidity  of  return  air  in  Illinois  mines  through- 
out the  year  averages  96  per  cent  and  the  temperature  averages  65  degrees 
F.  The  average  humidity  of  the  outside  air  in  Illinois  is  72  per  cent 
and  the  average  temperature  52  degrees."  Hence,  the  physical  con- 
dition of  mine  air,  with  the  exception  of  dust,  is  ideal  for  work.  The 
chemical  condition  is  rendered  so  through  close  obedience  to  the  mine 
laws  on  ventilation. 

Dust  is  the  chief  bane  of  coal  mine  air  for  the  vast  majority  of 
miners,  and,  speaking  from  a  health  point  of  view,  the  health  hazard  is 
in  proportion  to  its  composition  as  it  varies  from  coal  to  granite  dust. 

The  mine  inspection  system  of  the  State  is  concerned  chiefly  with 
the  prevention  of  accidents,  especially  explosions,  fires,  asphyxiations, 
and  the  collection  of  statistics.  For  the  purpose,  the  State  is  divided 
into  twelve  districts  beginning  with  jSTo.  I  at  the  north  and  ending  with 
No.  XII  at  the  south,  with  a  full  time  inspector  in  charge  of  each,  and 
with  an  inspector  in  each  county  to  assist  him.  Each  mine  also  has  one 
or  more  mine  examiners.     This  supervision  redounds  as  much  to  the 


380 

general  health  as  to  the  prevention  of  the  disasters  mentioned,  since  ade- 
quate ventilation  is  an  important  object  of  the  inspection  system. 

Practically  all  mines  are  infested  with  rats  or  mice,  and  sometimes 
both,  but  in  the  absence  of  epidemics,  such  as  plague,  they  have  little 
significance  as  a  health  hazard  to  miners.  Gnats  or  small  flies  are  also 
found,  but  they  are  few  in  number  and  consequently  of  small  menace  in 
the  mines.  In  the  absence  of  sanitary  privies  on  the  surface  the  carry- 
ing of  disease  from  excrement  to  food  and  to  houses  by  these  agents  con- 
stitutes a  considerable  menace. 

The  eight-hour  day  obtains  in  the  mines,  although  some  "company 
men"  may  work  as  long  as  ten  hours. Overtime  is  very  infrequent,  and 
night  work  is  limited  to  some  of  the  big  mines.  Absenteeism  averages 
about  10  per  cent  per  day  and  this  percentage  is  about  doubled  for  a  day 
or  two  following  payday,  which  occurs  twice  a  month.  Injuries  cause 
about  2  per  cent  of  total  absences.  The  lubor-turn-over  is  much  more 
pronounced  in  large  mines  and  mining  centers^  and  amounts  to  from  2 
to  30  per  cent  per  month. 

In  the  northern  and  west  central  coal  districts  Italians  predominate, 
while  Eastern  Europeans,  principally  Austrians,  Poles  and  Slavs,  form 
25  to  75  per  cent  of  employees  in  the  other  districts.  Colored  employees 
are  found  in  a  few  northern  and  central  mines  and  constitute  as  high  as 
75  per  cent  in  a  couple  of  large  mines  in  the  southern  part  of  the  State. 

An  inquir}^  into  the  ages  of  13,889  employees  (top  and  bottom)  at 
49  mines  visited  showed  2.6  per  cent  over  70  years  of  age;  3.5  per  cent 
between  60  and  69;  86.6  per  cent  between  22  and  59;  and  7.3  per  cent 
between  16  and  21. 

Wages  are  good  and  with  the  present  steady  work  the  pay  envelope 
is  large;  jiist  now  poverty  and  pauperism  are  practically  unknown.  In 
previous  years,  however,  many  mines  were  shut  down  for  some  months 
each  year  .  As  a  consequence  investigators  for  the  "Springfield  Survey" 
in  1915  found  that  many  mining  families  had  great  difficulty  in  making 
ends  meet  throughout  the  year. 

Health  hazards  vary  from  one  occupation  to  another.  The  occu- 
pational distribution  of  the  78,056  coal  mine  employees  reported  in  1917, 
was  as  follows : 

Cagers 753      Shot-firers    546 

Drivers 4,263     Timbermen .   1,422 

Laborers   5,660     Trackmen    2,178 

Loaders 24,529      Trappers    1,251 

Machine  men " 3,957     TJn-classified .   8,546 

Miners 24,951  ^ 

The  surf. ice  workers,  including  trackmen  and  some  of  the  unclassi- 
fied above,  totaled  7,'.J07. 

Investigation  showed  the  health  hazards  for  each  of  the  above 
classes  to  be  as  follows: 

Cagers. — Cagers  breathe  the  air  after  it  has  made  the  complete 
circuit  of  the  mine  (provided  the  return  air  is  by  way  of  the  hoisting 
shaft,  which  is  usually  the  case).     A  brisk  air  movement  is  also  present. 


381 

Fine  dust,  gasoline  motor  fumes  (when  such  motors  are  used,)  and  get- 
ting wet  with  water  drippings,  are  other  features. 

Drivers. — The  drivers,including  motormen,  trip-riders  and  mule 
drivers,  are  usually  youths.  The  work  is  dusty,  in  strong  drafts,  and 
hazards  exist  in  connection  with  motor  (fumes  or  electric  flashes). 

Laborers. — These  are  scattered  about  the  mme  and  have  the  hazards 
of  the  places  in  which  they  happen  to  work. 

Loaders. — These  workmen  are  subjected  to  air  conditions  of  the 
distant  interior  (work  rooms),  and  to  immense  amounts  of  dust.  Their 
work  is  laborious, '  on  the  tonnage  basis,  and  when  slack  periods  occur 
they  are  apt  to  sit  around  in  cool,  damp  places. 

Machine  men. — These  men  have  the  ventilation  hazards  of  the  work 
rooms,  and  are  the  most  subject  of  all  workers  .to  breathing  fine  dust 
(bug  dust).  Most  of  the  work  is  laborious  and  much  is  done  in  awk- 
ward positions. 

Miners. — The  work  of  the  miner  is  much  less  difficult  than  before 
the  days  of  the  extensive  use  of  powder.  They  have  the  ventilation 
hazards  of  the  work  room.  The  dust  hazard  is  great.  Their  work  is 
laborious,  on  the  tonnage  basis,  and  rather  monotonous  with  consider- 
able jar,  much  spurt  work  interspaced  with  spells  of  waiting  for  mine 
cars,  when  they  are  apt  to  sit  around  in  cool  atmospheres  and  damp 
places. 

Shot-firers. — Their  chief  hazards  are  the  breathing  of  dust  and 
oftentimes  white  damp  after  shooting. 

Timber  men. — These  men  have  the  "ventilation  hazards  of  work 
rooms  and  entries,  more  or  less  dust,  also  in  many  mines  more  or  less 
wet  work. 

Trappers. — Much  of  the  trappers'  time  is  spent  in  waiting  at  the 
doors,  which  they  watch,  or  the  switches.  They  may  be  in  strong  drafts 
carrying  various  amounts  of  dust.  They  are  usually  youths,  but  some- 
times old  men. 

Tipple  men. — These  workers  at  the  surface  of  the  coal  mine  have 
the  hazards  of  weather  exposure,  but,  more  especially,  the  breathing  of 
a  great  deal  of  coal  dust;  occasionally,  also,  smoke  and  fumes  from  the 
burning  dump  piles  where  these  exist.  The  weighmen  are  usually  in 
enclosed  quarters. 

Track  men. — Are  exposed  »to  the  weather,  and  the  breathing  of  a 
great  deal  of  coal  dust. 

Hoisting  engineers. — These  men  are  apt  to  be  exposed  to  excessive 
temperatures  (often  100°  to  140°  F.)  where  steam  hoists  are  used. 
This  is  a  dangerous  feature  since  they  must  be  constantly  on  the  alert, 
as  with  their  levers  they  guide  the  raising  and  lowering  of  cages  by 
means  of  signals  from  bells  or  whistles. 

Coal  washers. — In  the  case  of  these  men  we  find  weather  exposure 
with  wet  work  and  a  great  deal  of  dust  from  the  crushing  processes. 
Noise  is  a  marked  feature. 

Child  labor. — Is  practically  no  feature  in  Illinois  mines  for  youths 
under  sixteen  are  prohibited  by  law  from  entering  a  mine.     One  hazard 


382 

is  that  youths  begin  work  in  mines  without  preliminary  physical  examin- 
ation to  determine  whether  they  are  fit  for  such  work. 

Stripping  mines. — The  chief  health  hazards  are  weather  exposure, 
particularly  heat  in  the  summer  time  while  working  in  low  places.  Also 
men  in  steam  shovels  are  considerably  exposed  to  heat  from  furnaces. 

Some  Special  Hazaeds  need  discussion.     These  appertain  to  the 

work  of  most  miners. 

Illumination. — Illumination  is  no  longer  a  hazard  for  miners  since 
much  of  the  bottom  is  supplied  with  electric  lights  (207  mines  in  1915) 
and  miners  use  the  modem  carbide  lamps.  Oil  lamps  have  all  but  dis- 
appeared. Safety  lamps,  with  their  imperfect  illumination,  are  fortun- 
ately not  required  in  Illinois  mines. 

Heat. — Illinois  miners,  with  few  exceptions,  are  not  exposed  to 
high  working  temperatures.  Seventj^-eight  degrees  was  the  highest 
noted  underground,  which  was  at  the  upcast  in  the  deepest  mine  (1,004 
feet).     Hoisting  engineers  may  have  undue  exposures-. 

Cold. — The  temperature  of  Illinois  mines  is  invigorating — most  so  in 
the  shallow,  cool  mines.  As  long  as  workers  keep  active,  the  low  tem- 
peratures, unless  combined  with  work  in  mud  and  water  are  no  hazard. 

Fatigue. — Faulty  postures  and  work  of  jarring,  vibrative  character, 
heavy  lifting  at  times,  and  a  certain  percentage  of  men  ill-fitted  physically 
for  the  work  are  the  chief  hazards. 

Honrs  of  loorTc. — The  eight-hour  day,  with  very  little  overtime, 
obtains  at  mines.     Some  company  men  (laborers)  work  ten  hours. 

Infections. — The  disposals  of  stools  in  the  gob,  as  is  the  prevailing 
method,  can  be  made  safe.  Illinois  mines  are  too  dry  to  afford  much 
hazard  in  the  spread  of  hookworm  disease.  The  extent  to  which  coal 
mine  dust  may  transport  virulent  germs,  as  from  spitting,  has  not  been 
investigated;  the  hazard  is  probably  insignificicant.  Diseases  from 
animals,  such  as  anthrax,  glanders  and  lockjaw,  do  not  appear  to  exist. 
In  the  presence  of  the  black  plague  the  rats  and  mice  in  mines  would  be 
a  great  menace.  Injuries  which  miners  receive  are,  (if  not  more  free), 
at  least  as  free  from  secondary  infections  as  in  most  kinds  of  work. 

Electricity. — In  addition  to  burns  and  shocks,  and  occasionally 
electrocutions,  the  witnessing  of  brilliant  electric  flashes,  occasions  some 
electrica  ophthalmia — a  painful  swelling  of  the  eyes  which  may  persist 
up  to  fourteen  days. 

Poisons. — These  concern  mine  gases  principally  {q.  v.)  Occasion- 
ally sulphurous  waters  cause  dangerous  inflammation  of  the  eyes  when 
they  gain  access  to  them. 

Assuaging  of  thirst. — Questionable  water  supplies  in  many  instances 
lay  miners  liable  to  typhoid  fever,  dysentry,  and  water  borne  diseases. 
Alcholic  beverages  are  not  permitted  while  at  work. 

Personal  hygiene.— Miners  are  in  great  need  of  instruction  in 
matters  of  personal  hygiene  and  the  prevention  of  sickness.  A  large 
number  of  miners'  illnesses  could  be  avoided  by  this  means. 


383 

Geneeal  Sanitary  Conveniences  at  mines  may  be  summarized 
under  a  few  headings  as  follows: 

Wash  houses. — Practically  all  mines  have  wash-houses  located  near 
the  entrance  to  the  mine.  This  is  required  by  law.  A  majority  of  them 
are  not  of  sufficient  capacity  and  also  are  not  separated  from  clothes- 
drying  quarters,  which  should  be  the  case.  Most  have  shower  baths; 
many  have  simply  pans,  buckets  or  tubs,  especially  where  water  is  scarce. 
Complaints  of  insufficient  heating  of  bath-houses  are  frequent.  They 
are  also  often  poorly  ventilated.  Drainage  from  them  is  frequently 
dangerous  to  water  supplies.  Their  use  has  greatly  increased  so  that  at 
present  upwards  of  70  to  95  per  cent  of  the  employees  use  them.  By 
tradition,  miners  bathe  completely  every  day  where  opportunity  is 
offered.  In  the  past  this  was  done  at  the  home.  Wash-house  quarters 
are  supplied  and  maintained  by  the  operators.  The  employees  furnish 
soap,  towels  and  locks. 

Clothing  provisions. — A  place  to  hang  clothes  is  provided  at  prac- 
tically all  mines.  In  the  vast  majority  of  cases  this  provision  is  in  the 
wash-house.  Lockers  were  found  about  as  often  as  ceiling  hooks  or 
hangers  upon  w^hich  the  clothes  are  hung  and  pulled  up  to  the  ceiling 
by  means  of  a  rope  and  pulley.  Many  mines  have  neither,  in  which 
case  the  men  use  nails  or  pegs  along  the  walls  of  the  wash  room.  Too 
great  crowding  was  frequently  noticed.  Lack  of  screens  against  flies 
wa^  common.  The  ideal  arrangement  is  a  room  partitioned  off  from 
washing  quarters,  equipped  with  ceiling  hooks  for  work  clothes  and 
lockers  for  street  clothes. 

Water  supplies. — Water  for  drinking  purposes  is  usually  not  ob- 
tained at  the  mine,  but  is  brought  by  the  employees  in  their  lunch 
buckets.  Wells  in  the  neighborhood  of  the  mines,  oftentimes  in  very 
poor  sanitary  condition,  are  the  usual  sources  of  water  for  drinking  pur- 
poses. In  many  districts  the  prevailing  type  of  well  is  boxed  around  at 
the  top  and  left  open,  with  a  rope  and  bucket  for  drawing  water.  Un- 
doubtedly much  typhoid  fever  and  dysentery  in  mine  districts  are  due 
to  lack  of  attention  to  the  source  of  drinking  water  supplies.  Scarcity 
of  water  is  serious  in  some  districts.  Hydrochloride  disinfection  could 
be  provided  at  small  expense  at  every  mine. 

Sewage  disposal. — Mines  do  not  have  toilet  facilities  below  ground. 
The  men  at  work  simply  use  the  gob  piles.  In  dry  mines  there  is  little 
hazard  from  this  practice,  provided  care  is  taken  by  each  miner  to  cover 
his  stool.  In  many  mines  portable  trench  buckets,  or  closets  mounted 
on  trucks,  could  be  used.  At  the  surface,  where  from  a  few  to  fifty  men 
are  employed,  the  vast  majority  of  mines  provide  nothing  in  the  way  of 
a  latrine,  much  less  a  sanitary  one,  for  the  workmen.  Instead,  the 
latter  usually  seek  the  neighboring  dirt  piles,  fields,  timber  or  hillsides. 
On  account  of  this  lack  the  flies  and  insects  about  mines  and  mining 
towns  are  special  menaces  as  disease  carriers.  A  standard  privy  for  the 
surface  workers  at  a  mine  could  be  constructed  at  very  little  cost. 

Lunch  provisions. — Each  employee  at  a  coal  mine  invarably  carries 
his  own  lunch  in  a  specially  constructed  miner^s  lunch  bucket,  which  is 
provided  with  a  water  compartment.     The  30-minute  lunch  hour  pre- 


384 

vails.     Occasionally  workmen  at  the  surface  may  have  opportunity  to 
lunch  at  home. 

III.   HOUSING     CONDITIONS    AND    LOCAL    HEALTH    ADMINISTRATION. 

The  community  has  a  large  place  in  determining  the  diseases  of 
miners.  Very  often  the  chief  afflictions  are  favored  by  unsanitary 
housing  conditions,  unsafe  water  supplies,  poor  sewage  disposal,  poor 
food  supervision  and  weak  local  health  administration. 

The  hygiene  aud  sanitation  of  dwelling  places  is  important  since 
it  involves  about  one-third  of  the  normal  day  for  the  worker  and  most  of 
the  time  for  his  family.  While  some  Illinois  mines,  as,  for  instance, 
those  at  Springfield,  Belleville,  and  about  Peoria  and  La  Salle,  are  lo- 
cated in  or  close  to  large  cities,  as  a  rule  mining  towns  are  composed  of 
a  store  or  two  around  which  very  plain  frame  dwellings  or  shanty  houses 
group  themselves.  While  one  or  two  communities,  as  the  one  at 
Divernon,  are  found  model  in  regard  to  building  construction  and  ar- 
rangement, and  upkeep,  and  while  the  men  in  a  few  other  communities 
are  not  poorly  housed,  the  great  majority  of  the  mining  centers  present 
a  housing  problem.  Moreover,  safe  sanitary  standards  as  regards  both 
water  supplies  and  sewage  disposal  were  nowhere  encountered.  The 
typical  mining  town  consists  of  rows  of  dingy  houses,  all  built  after  one 
or  two  patterns,  often  located  on  hillsides,  with  rows  of  privies  located 
close  to  wells  or  draining  toward  the  wells  on  the  next  street.  Often 
small  ditches  of  water  act  as  open  sewers,  and  seldom  is  any  provision 
made  for  the  disposal  of  garbage.  Screens  for  houses  are  usually  pro- 
vided by  the  occupant  if  present  at  all. 

Many  mining  towns  are  unincorporated.  Often  there  is  no  local 
health  officer.  The  board  of  health  consists  of  the  mayor  and  two  or 
more  members  of  the  council  in  the  larger  towns.  In  many  cases,  only 
the  township  supervisor  arrangement  prevails.  Very  often  the  health 
officer  is  not  a  physician  and  is  entirely  unskilled  in  matters  of  hygiene 
and  sanitation.  Very  often  he  belongs  to  the  old  type  of  health  officer, 
who  lays  stress  on  rubbage,  ash-dumps,  foul  smells,  and  fumigation,  but 
pays  little  attention  to  wells,  privies,  screening,  milk  supply,  or  the 
prompt  isolation  and  concurrent  disinfection  of  a  case  of  communicable 
disease. 

To  the  above  notes,  a  few  excerpts  from  a  report  by  Mr.  Skoog  may 
be  added. 

"The  drainage  from  the  mines  was  found  to  be  rather  unsatisfactory 
m  most  cases.  Open  ditches  were  generally  used  for  the  removal  of 
w^te  water.  Where  creeks  were  in  close  proximity  to  the  mine,  the 
effluent  was  directed  to  them.  In  many  cases  manure  was  found  in  large 
quantities  near  the  shaft  and  flies  were  noticeable  in  large  quantities. 

In  very  few  cases  were  sanitary  flush  toilets  found  on  the  surface 
at  the  mines. 

"The  public  health  protection  as  afforded  in  98  per  cent  of  the 
towns  visited  was  found  to  be  very  unsatisfactory.  The  methods  of 
handling  communicable  diseases  is  old  and  not  in  accord  with  modern 


385 

methods.  In  some  communities  persons  quarantined  were  required  to 
pay  for  fumigation  and  in  other  communities  the  health  officer  or  under- 
taker did  this  at  a  cost  to  the  town  of  $5  for  fumigation. 

"A  large  per  cent  of  the  towns  visited  were  without  sewers  and  con- 
sequently privies  were  the  common  method  of  excreta  disposal.  Shallow 
wells  were  also  in  use. 

"The  housing  conditions  vary.  In  Divernon,  for  exampe,  the  coal 
company  has  constructed  100  four-room  bungalows.  The  style  of  archi- 
tecture varies  and  there  is  not  the  monotony  usually  found.  The  sur- 
roundings are  comparatively  clean  and  attractive.  In  most  other  com- 
munities the  houses  are  poorly  cared  for.  The  general  sanitary  con- 
ditions were  found  to  be  unsatisfactory. 

"Generally  speaking,  the  living  conditions  in  coal  mining  communi- 
ties are  poor  and  unattractive.  The  working  conditions  of  the  miners 
are  much  better  than  the  living  conditions." 

IV.    SICKNESS TYPES   AND   EXTENT. 

There  are  two  methods  of  inquiry  into  types  and  extent  of  sickness : 
first,  statistics,  and  second,  opinions  of  persons  qualified,  through-  ex- 
perience or  practice,  to  impart  information. 

Practically  no  statistics  are  available  concerning  sickness  among 
Illinois  coal  miners.  Unfortunately,  the  bookkeeping  of  vital  statistics 
has  not  extended  this  far.  Some  of  the  local  unions  and  benevolent 
associations  can  supply  certain  limited  statistics  but  these  are  too  local 
to  warrant  drawing  conclusions  therefrom.  The  exoneration  (the  non- 
dues-paying)  lists  of  the  State  organization  (U.  M.  W.  A.)  do  not  separ- 
ate sickness  from  other  causes  of  the  members  not  being  at  work.  Hos- 
pital statistics  in  mining  districts  are  not  representative,  however 
complete  they  may  be,  since  an  unknown  percentage  of  miners  go  to 
hospitals  when  sick.  No  insurance  companies  have  to  date  taken  out 
group  policies  covering  sickness,  among  other  disabilities,  among  miners. 

Under  the  circumstances  we  must  rely  chiefly  on  physicians  in 
mining  centers  for  the  information  desired.  The  experience  of  physi- 
cians, scattered  throughout  the  district,  particularly  where  they  agree 
quite  unanimously,  are  probably  more  likely  to  be  a  close  analysis  of 
the  sickness  situation  than  any  conculsions  which  might  be  drawn  from 
statistics.  The  following  is  a  summary  of  statements  entered  on  the 
questionnaire  by  which  physicians  were  personally  interviewed  in  min- 
ing communities: 

(a)  Disease  rarely  found  among  miners. — Certain  diseases  reputed 
to  be  prevalent  among  miners  elsewhere  or  to  be  suspected,  were  found 
to  be  practically  absent  among  Illinois  miners.  These  are  lockjaw, 
anthrax,  glanders,  hookworm,  rat-bite  disease,  and  nystagmus. 

(b)  Disease  found  less  frequently  than  usual. — Pneumonia  (except 
among  Xegro  miners  where  it  seems  to  be  more  prevalent)  ;  tuberculosis 
(that  which  occurs  is  generally  of  a  very  slow  progressive  type,  difficult 
to  separate  from  miner's  asthma)  ;  and  venereal  diseases.  However,  it 
must  be  noted  that  according  to  death  certificates  filed  by  coal  miners 

—25  HI 


386 


in  the  State,  pneumonia  exceeds  the  prevailing  percentage  for  this  dis- 
ease in  the  populace  while  tuberculosis  approximates  it.  This  is  greatly 
emphasized  if  the  deaths  from  violence  are  excluded. 

(c)  Diseases  having  the  usual  frequency. — Acute  rheumatic  fever; 
afflictions  of  the  upper  respiratory  tract,  such  as  colds,  tonsilitis,  middle 
ear  diseases,  nose,  throat  and  sinus  affections,  acute  broncnitis,  eye  afflict- 
ions, although  the  communicable  disease,  trachoma,  or  granulated  eye- 
lids, was  frequent  in  some  localities;  skin  affections;  foot  affections; 
deformities;  nervous  affections;  hernias;  varicose  veins;  other  chronic 
diseases  in  general ;  malaria ;  epidemic  diseases  such  as  influenza,  small- 
pox and  summer  diarrhoea. 

(d)  Diseases  with  occupational  earmarh. — These  are  "rheumatism," 
asthmatic  afflictions,  and  afflictions  due  to  alcoholic  beverages.  The 
"rheumatism"  is  of  the  type  unassociated  with,  fever,  called  musculo- 
articular,  of  which  lumbago  is  the  chief  form,  and  so-called  "sciatica" 
the  next.  Exposure  to  cool  damp  atmospheres,  drafts,  the  weather,  and 
sudden  straining  efforts  on  the  part  of  men  not  physically  adapted  to 
their  work,  are  underlying  causes.  Asthma  is  a  disease  decreasing  in 
frequency.  Bad  ventilation  including  dust  probably  still  plays  the 
chief  part  in  its  cause,  but  organic  heart  disease  or  other  chronic  dis- 
eases are  becoming  principal  reasons  for  what  asthma  is  found.  Asthma 
is  rarely  found  in  individuals  under  forty  years  of  age.  About  one  or 
two  working  men  in  a  hundred  are  reported  as  asthmatics.  Alcoholism 
is  exceedingly  common,  perhaps  more  so  than  in  other  industries,  since 
it  seems  to  be  traditional  among  a  considerable  number  of  miners  to  take 
a  day  or  so  off  after  each  pay-day  for  an  alcoholic  debauch.  Other 
afflictions  are  dust  plugs  in  the  ears  (of  no  consequence  but  causing 
some  temporary  deafness) ;  eyes  flashed  by  electric  short  circuits ;  "sul- 
phur" ulcers  due  to  getting  sulphurous  waters  in  the  eyes ;  callosites  on 
knees  and  sometimes  elbows,  hands  and  shoulders,  mostly  in  "low  coal" 
districts;  "gassing^'  due  principally  to  accidental  breathing  of  white 
damp  after  blasting,  fires  or  explosions;  and  premature  aging — though 
this  not  in  a  marked  degree. 

General  summary  of  diseases. — There  is  no  reason  for  believing 
that  the  usual  afflictions,  outside  of  the  respiratory  system  and  the  mus- 
culo-osseous  system,  are  more  frequent  among  miners  than  among  other 
employees.  In  fact,  they  are,  as  a  class,  probably  healthier  than  the 
average  type  of  factory  worker.  Top  workers,  exposed  to  the  weather, 
are  said  to  have  more  sickness  than  those  in  the  mine.  Alcoholism  is  far 
and  away  the  chief  bane.  It  is  said,  however,  to  be  decreasing — a  fact 
explained  by  one  physician  as  due  to  education,  increasing  cost  of  alco- 
holic drinks,  their  present  bad  quality,  and  the  extension  of  prohibition. 
Of  the  respiratory  afflictions,  chronic  bronchitis  associated  with  asthmatic 
symptoms,  and  often  complicated  by  a  chronic  form  of  tuberculosis,  are 
undoubtedly  more  prevalent  than  among  agriculturists.  Some  comment 
was  made  on  the  number  of  draftees  returned  to  coal  mining  counties, 
but  inquiry  at  the  State  Department  of  Health  showed  that  most  of  these, 
curiously  enough,  were  agriculturists  rather  than  miners.  The  num- 
bers, however,  were  too  few  to  warrant  deductions.     Hospital  experience, 


387 


as  at  the  West  Frankfort  Miners'  Hospital,  showed  that  the  principal 
medical  afflictions  for  which  the  miners  came  into  the  hospital  were 
typhoid  fever,  malaria,  pneumonia,  tuberculosis  and  rheumatism.  At 
the  company  hospital  at  Zeigler  the  physician  in  charge  listed  as  most 
prevalent  chronic  bronchitis  with  emphysema  and  asthma,  some  acute 
iheumatic  fever,  sacro-iliac  affections,  acute  bronchitis,  ear  plugs,  and 
nasal  sinus  afflictions,  with  typhoid  epidemics  at  times  and  trachoma 
fairly  common.  There  had  been  but  one  case  of  lockjaw  in  six  years 
experience,  in  spite  of  the  fact  that  anti-tetanic  serum  was  only  rarely 
administered.  "Flashed  eyes"  were  fairly  common;  malaria  frequent. 
In  this  place  no  case  of  hookwomi  was  ever  discovered  in  a  miner. 

V.    MORTALITY. 

Illinois  leads  all  other  states  in  having  available  (through  the 
efforts  of  the  United  Mine  Workers  in  the  State)  figures  on  the  average 
number  of  employees  at  a  given  time  in  the  soft  coal  industry  and  a 
record  of  each  coal  miner's  death  for  the  past  ten  years.  These  records 
have  resulted  from  the  insurance  maintained  by  the  organization  by 
which  the  sum  of  $250  is  paid  to  the  beneficiary  on  the  occasion  of  the 
death  of  any  miner  in  good  standing.  In  order  that  former  or  un- 
employed miners  may  remain  in  good  standing  and  thus  insure  the  burial 
payment  an  "exoneration"  (non-dues-paying)  list  is  maintained  to  which 
7  per  cent  of  the  total  number  of  miners  now  belong.  The  exoneration 
list  has  recently  been  extended  from  5  per  cent  of  the  total  membership 
to  7  per  cent,  because  of  the  exonerations  allowed  for  War  Service. 

These  records  have  enabled  the  Commission  and  the  writer  to  com- 
pile the  fallowing  Tables  (II,  III,  IV,  V,  VI)  : 

TABLE  II — MORTALITY  AMONG  ILLINOIS  COAL  MINERS. 
(February  1,   1912,  to  July  21,  1918.) 


Fiscal  year. 


Number  of 
deaths. 


Average 
yearly 

member- 
ship. 


Deaths  per 

annum 
per  100,000 
employed. 


Feb.  1,  1912-1913 

Feb. 1,  1913-1914 

Feb.  1,  1914-1915 

Feb.  1,  1915-1916 

Feb.  1, 191&-1917 

Feb.  1, 1917-Jan.  1, 1918 
Jan.  1, 191S-July  1, 1918 


742 

73, 955 

800 

75, 161 

825 

76,093 

784 

70,903 

832 

74, 942 

893 

83,489 

555 

93,651 

1,003 
1,064 
1,071 
1,105 
1,110 
1,167 
1,185 


The  last  column  in  Table  II  shows  the  death  rate  for  Illinois  coal  miners  has 
been  constantly  increasing  since  1912. 


388 


TABLE  III— MORTALITY  OF  ILLINOIS   COAL  MINERS   BY   SELECTED 

CAUSES    OF    DEATH. 

(FEBRUARr  1,  1912,  TO  JuLY  21,  1918,  Approximating  6^  Years.) 


Cause  of  death'. 


International 
list  No.  (s). 


For  the 
four  year 

genod 
.  1, 1912, 
to  Jan.  31, 
1916.* 


For  the 

geriod 
.  1, 1916, 
to  July  21, 
1918.t 


Total 

number  of 

deaths  Feb. 

1,  1912,  to 

July  21, 

1918. 


Percentage 

distribution 

of  deaths, 

per  cent. 


Deaths 
per  annum 
per  100,000 
employed. t 


Typhoid  fever 

Malaria 

Tetanus 

Tuberculosis 

Cancer 

Cerebro-spinal  diseases . 

Circulatory  diseases 

Pneumonia 

Other  respiratory   dis- 
eases   


Liver  cirrhosis . 
Geiiito-uriiiary 

venereal) 

Suicide 

Violence** 

All  others 


(non- 


Total. 


1 

4,4a 

24 

28  to  35... 
39  to  46.. 
60  to  79.. 
77  to  85... 
91  and  92. 


86  to  90  93  to 

98 

113,113a , 


119  to  127.. 
155  to  163.. 
164  to  186.. 
All  others . 


104 
6 
5 
277 
109 
153 
212 
252 


158 

47 

124 

102 

1,205 

408 


3,162 


50 

5 

1 

221 

98 

135 

.190 

239 


55 
41 

129 

58 

790 

254 


2,266 


154 
11 
6 
498 
207 
288 
402 
491 


213 
88 

253 

160 

1,995 

662 


5,428 


2.8 
0.2 
0.1 
9.2 
3.8 
5.3 
7.4 
9.1 


3.9 
1.6 


4.7 

3.0 

36.8 

12.2 


100.1 


30.8 
2.2 
1.2 
99.4 
41.4 
57.5 
80.3 
98.1 


42.6 
17.6 

50.5 

31.9 

398.2 

132.1 


1,083.9 


*  From  figures  compiled  by  Duncan  McDonald,  former  Secretary-Treasurer, 
U.  M.  W.  A.,  District  of  Illinois. 

t  From  death  claim  records  at  office  of  Walter  Nesbit,  Secretary-Treasurer, 
U.  M.  W.  A.,  compiled  by  the  Commission. 

t  The  average  monthly  number  of  employees  throughout  the  whole  period  of 
approximately  six  and  one-half  years  was  77,051. 

**  "Violence"  includes  all  external  causes  other  than  suicide. 

Some  deductions  based  on  Table  III  may  be  made  by  comparisons 
with  "percentage  distribution  of  deaths"  in  other  groups,  which  have 
been  computed  elsewhere,  as: 

(a)  The  United  States  Eegistration  Area  for  5,663  "miners  and 
quarrymen''  as  given  in  Mortality  Statistics,  United  States  Bureau  of 
Census,  1909,  Table  VIII,  pages  402-403  (see  Tables  IV  and  V  below) ; 
and 

(b)  The  United  States  Eegistration  Area  for  210,  507  "occupied 
males  10  years  of  age  and  over"  as  given  in  Mortality  Statistics,  United 
States  Bureau  of  Census,  1909,  Table  VIII,  pages  388-389  (see  Tables 
IV  and  V  below).  ^ 


389 


TABLE  IV- 


-PERCENTAGE  RATES  OF  CERTAIN  CAUSES  OF  DEATH  FOR 
ILLINOIS  COAL  MINERS  AND  OTHER  GROUPS. 


Causes  of  deaths.* 


5,428 

deaths  among 

lUinois  coal 

miners, 

1912-1918— 

per  cent. 


5,663  deaths 
among  miners 
and  quarry- 
men,  U.  S. 
Reg.  Area, 

1909— 
per  cent. 


210.507 
deaths  among 

occupied 

males,  U.  S. 

Reg.  Area, 

1909— 
per  cent. 


Typhoid  fever 

Tuberculosis 

Cancer 

Cerebro-spinal 

Circulatory  disease 

Pneumonia 

Other  respiratory  diseases 

Liver  cirrhosis 

Genito-urinary  (non-venereal) 

.Suicide 

Violencef 


2.8 
9.2 
3.8 
5.3 
7.4 
9.1 
3.9 
1.6 
4.7 
3.0 
36.8 


2.3 

t8.8 
3.3 
4.9 
8.8 
8.2 
4.3 
1.0 
4.0 
1.5 

39.1 


2.2 

tu.s 

5.5 

9.8 
16.1 

8.0 
10.2 

1.8 
**8.5 

2.6 
10.6 


*  See  Table  III  for  corresponding  International  List  Numbers, 
t  See  Note  4,  Table  III. 
t  Tuberculosis  of  lungs,  only. 
**  Bright's  disease. 

While  it  is  true  that  comparisons  as  arranged  in  Table  TV  are  not 
quite  logical,  principally  because  periods  of  even  date  are  not  compared, 
but  also  because  soft  coal  miners  have  not  been  separated  out,  they  are 
the  best  that  can  be  had  at  present. 

Violence  as  a  cause  of  death  of  Illinois  coal  miners  ranks  2.3  points 
less  than  that  of  "miners  and  quarrymen^'  in  the  Registration  Area. 
This  cause,  however,  for  both  Illinois  coal  miners  and  "miners  and 
quarrymen"  is  greatly  in  excess  of  the  violence  percentage  in  "occupied 
males"  in  the  Registration  Area  (10.6  per  cent  of  all  deaths).  But 
one  other  occupation,  "Steam  railway  employees,"  with  53.6  per  cent 
of  all  deaths  due  to  violence,  surpasses  "miners  and  quarrymen."  The 
occupation  ranking  next  is  "lumbermen  and  raftsmen"  with  29.9  per 
cent  (United  States  Mortality  Statistics,  1909,  Table  VIII).  The 
marked  excess  in  this  cause  of  death  nullifies  to  a  large  extent  any  com- 
parisons possible  between  the  other  causes  of  death  and  the  figures  given 
under  "occupied  males"  in  the  last  column.  It  does  not  however  affect 
comparisons  between  "Illinois  coal  miners"  and  "miners  and  quarrymen." 

By  eliminating  the  distortion  due  to  violence  as  a  cause  of  death 
and  then  comparing  the  purely  medical  causes  (plus  suicide)  a  clearer 
insight  is  obtained  of  the  relative  importance  of  certain  prominent  death 
causes. 


390 


TABLE    V— PERCENTAGE    RATES    OF    CERTAIN    CAUSES    OP    DEATH    FOR 
ILLINOIS  COAL  MINERS  AND  OTHER  GROUPS,  VIOLENCE  EXCLUDED. 


Causes  of  deaths. 


5,428 

deaths  among 

Illinois  coal 

miners, 

1912-1918— 

per  cent. 


5,663  deaths 
among  miners 
and  quarry- 
men,  U.  S. 
Reg.  Area, 

1909— 
per  cent. 


210,507 
deaths  among 

occupied 

males,  U.  S. 

Reg.  Area, 

1909— 
Ijer  cent. 


-.4 

4 


Typhoid  fever 

Tuoerculosis 

Cancer 

Cerebro-spinal 

Circulatory  diseases 

Pneumo  lia 

Other  resoiratory  diseases 

Liver  cirrnosis 

Ge  1  to-urinary  (non-ver ereal) 
Suicide 


4.4 

14.6 

6.0 

8.4 
11.7 
14.4 
6.2 
2.5 
7.4 
4.7 


3.8 

*14.4 

5.4 

8.0 

14.5 

13.5 

7.1 

1.6 

6.6 

2.5 


I 


2.5 
*16.6 

6.2 
11.0 
18.0 

8.9 
11.4 

2.0 
t9.5 

2.9 


•  Tuberculosis  of  lungs,  only, 
t  Bright's  disease. 

As  compared  with  "miners  and  quarr}^men"  in  general,  Illinois  coal 
miners  rank  ( 1 )  about  the  same  with  respect  to  tuberculosis  and  cerebro- 
spinal diseases;  (2)  more  favorable  with  respect  to  circulatory  diseases; 
and  "other''  respiratory  diseases ;  and  ( 3 )  less  favorable  with  respect  to 
typhoid  fever,  urinary  (non-venereal)  diseases  and  suicide.  As  com- 
paied  with  "occupied  males/'  in  general,  Illinois  coal  miners  rank  (1) 
about  the  same  with  respect  to  cancer  and  liver  cirrhosis;  (2)  more 
favoiable  with  respect  to  tuberculosis  (which  is  more  pronounced  when 
total  tuberculosis  is  considered),  cerebro-spinal  diseases  circulatory  dis- 
eases, "other"  respiratory  diseases,  and  genito-urinary  (non- venereal) 
diseases;  and  (3)  much  less  favorable  with  respect  to  typhoid  fever, 
pneumonia  and  suicide. 

Unfortunately,  similar,  more  recent  figures  have  not  been  compiled 
by  the  Census  Bureau,  nor  does  this  agency  compute  "death  rates"  among 
employed  persons.  Mortality  statistics  for  soft  coal  miners  or  groups 
with  similar  hazards  in  other  states  have  not  been  prepared.  Table  VI, 
however,  permits  some  conclusions  to  be  drawn  from  the  "death  rates" 
ascertained. 


391 


TABLE  VI — MORTALITY  OF  ILLINOIS  COAL  MINERS  BY  CAUSES 

AND    AGE-GROUPS. 

(July  22,   1916,  to  July  21,  1918.) 


r 

Age  groups. 

Causes  of  death.* 

15-24 

25-34 

35-44 

45-54 

55-64 

65  or 
over. 

Age  not 
given. 

Total. 

is? 

B 

* 

<D 

O 

« 
Pi 

s 

3 

* 

S3 

o 

Ph 

a 

t 

a 

o 

Pm 

<o 

Xi 

a 

3 

* 

s 

& 

B 

Ph 

s 

3 

* 

5 

o 

« 

Pi 

a> 

3 

* 

a 
o 

Ph 

a 

3 

+- 

c 
o 
o 

Ph 

©gTS  1/1 
P? 

Tuberculosis  . 

26 

14.6 

47 

7 

9 

17 
36 

6 
2 

9 

26.4 
9.2 

7.6 

11.2 
18.1 

3.3 
5.4 

8.8 

35 
15 

24 

18 
39 

4 
9 

11 

19.6 
9.7 

20.5 

11.9 
19.6 

8.8 
24.3 

10.7 

33 
20 

25 

36 
49 

11 

8 

19 

18.6 
26.3 

2L3 

23.8 
24.7 

24.4 
21.6 

18.6 

24 
22 

27 

38 
38 

7 
12 

38 

13.4 
28.9 

23.0 

25.1 
19.1 

15.5 
32.4 

37.2 

13 
12 

22 

36 
26 

16 
3 

22 

7.3 
15.7 

18.8 

23.8 
13.1 

35.5 
8.1 

2L5 

178 
76 

117 

151 
198 

45 
37 

102 

49 

676 

260 

9.4 
4.0 

6.1 

7.9 
10.4 

2.3 
1.9 

5.3 

2.5 

35.7 

13.7 

106.5 

Cancer 

45.4 

Cerebro-spinal  dis- 
eases  

9 

6 
10 

1 
3 

2 

7.6 

3.9 
5.0 

2.2 
8.1 

1.9 

1 

0.9 

70.0 

Circulatory 
diseases 

90.3 

Pneumonia  . 

118.5 

Other  respiratory 
diseases 

26.9 

Liver  cirrhosis. . . . 

22.1 

Genito-urinary 

non-venereal 

Suicide 

1.0 

61.0 
29.3 

Violencef 

404.6 

All  others 

41 

15.7 

55 

21.1 

44 

16.7 

141 

15.7 

32 

12.3 

42 

16.1 

5 

1.9 

155.6 

Total 

1,889 

99.2 

1,130.2 

*  See  Table  III  for  corresponding  International  List  Numbers 

t  See  Note  4,  Table  III. 

J  The  averag-e  monthly  employment  vv^as  83,537  men. 

**  %  here  means  the  distribution  of  deaths  by  age-groups,  per  100  deaths  from 
the  given  cause. 

ft  %  here  means  the  distribution  of  deaths  by  causes,  per  100  deaths. 

Table  VI  is  valuable  in  two  ways :  ( 1 )  It  shows  the  age-groups  in 
wliich  certain  diseases  are  emphasized  in  Illinois  coal  miners,  and  (2) 
when  related  lo  Table  III,  it  indicates  the  increasing  or  decreasing  im- 
portance of  certain  diseases  as  causes  of  death. 

(1)  Tuberculosis  shows  its  main  emphasis  in  the  age-group  25  to 
34,  with  a  gradual  decline  thereafter  throughout  the  balance  of  the  age- 
periods. 

Pneumonia  shows  a  gradual  increase  with  age  up  to  the  age-period 
45-54,  then  a  gradual  decline. 

The  figures  for  other  respiratory  diseases  are  too  small  for  de- 
ductions, but  in  general  show  most  emphasis  later  in  life. 

Cancer  and  cerebro-spinal  diseases  both  show  a  marked  incraese  in 
the  age-period  35  to  44,  then  a  more  gradual  increase  to  age  64,  after 
which  there  is  a  decline. 

Circulatory  diseases  are  emphasized  from  45  years  of  age  up. 

For  Liver  cirrhosis  the  figures  are  too  limited  for  speculation  al- 
though the  majority  of  deaths  occur  in  the  age-periods  between  35  and 
64. 

The  non-venereal  genito-urinary  afflictions  (principally  Bright' s 
disease)  show  a  gradual  increase  by  age-period  up  to  and  including  the 
age-period  55-64. 


^^^^^^I^^P  392      ^l^^^^^^^^^^^l 

^^Tke  figures  for  mioide  and  violence  were  not  obtained  by   age^ 

periods.  i      .  xi. 

All  other  diseases  have  a  very  even  distribution  throughout  the  age- 
periods,  there  being  emphasis  on  the  period  25-34  and  less  emphasis  m 

the  period  55-64. 

(2)  Comparing  the  last  column  in  Table  VI  which  shows  death 
rates  by  cause  for  the  years  1916-1918  with  the  last  column  in  Table 
III,  which  shows  death  rates  by  cause  for  the  years  1912-1918,  it  is  found 
that  the  rates  per  100,000  employed  have  increased  for  the  following 
afflictions:  tuberculosis  (from  99.4  to  106.5),  cancer  (from  41.4  to  45.4), 
cerebro-spinal  diseases  (from  57.5  to  70.0),  circulatory  diseases  (from 
80.3  to  90.3,  pneumonia  (from  98.1  to  118.5),  liver  cirrhosis  (from  17.6 
to  22.1),  and  genito-urinar}^  (non-venereal)  diseases  (from  50.5  to  61.0). 
Deaths  from  the  folowing  causes  show  decreasing  rates:  other 
respiratory  diseases  (from  42.6  to  26.9),  and  suicide  (from  31.9  to  29.3). 
Violence  (increasing  from  398.2  to  404.6)  did  not  change  substantially. 
The  1889  deaths  occurring  in  the  two-year  period,  July  22,  1916 
to  July  21,  1918  (see  Table  VI)  were  classified  also  by  the  twelve  dis- 
tricts composing  the  coal  field  of  the  State.  Without  exhibiting  the 
table,  the  following  could  be  deduced: 

(a)  The  total  of  5  deaths  from  malaria  all  occurred  in  the  last  four 
(southern)  districts. 

.(b)  The  total  of  42  deaths  from  typhoid  fever  were  distributed,  12 
in  Franklin  county,  9  in  Williamson  and  Johnson  counties,  (these  two 
constitute  a  district) ,  and  the  balance  scattered. 

(c)  All  the  remaining  causes  of  death  were  fairly  evenly  distributed 
in  proportion  to  the  number  of  employees  in  the  several  districts. 

Summary  of  mortality  statistics. — The  annual  death  rate  of  Illinois 
coal  miners  has  been  increasing  since  1912.  Death  rate  comparisons 
with  exactly  like  groups  elsewhere  cannot  be  made  because  similar 
statistics  elsewhere  have  not  been  compiled.  The  per  cent  of  deaths  from 
different  causes  shows  that  rates  for  Illinois  miners  are  about  the  same 
as  for  "miners  and  quarrymen"  in  the  Eegistration  Area,  1909,  and  that 
for  this  class  of  employees,  external  causes  (violence  and  suicide) 
account  for  two-fifths  of  the  deaths.  When  violence  is  excluded  typhoid 
fever  and  pneumonia  stand  out  with  prominence,  particularly  when  com- 
pared to  occupied  males  in  general. 

It  is  hardly  more  than  speculation  to  attempt  to  state  to  what  the 
increase  in  mortality  among  Illinois  coal  miners  is  due.  Working  con- 
ditions are  undoubtedly  getting  better  from  year  to  year.  Unquestion- 
ably it  cannot  be  charged  to  any  single  factor,  such  as  alcoholism,  which 
has  been  decreasing  throughout  the  period  covered  in  the  Tables;  nor 
fatigue,  since  work  hours  have  decreased  while  the  assistance  of  blasting 
powder  and  machinery  have  increased ;  nor,  with  the  exception  of  certain 
diseases  like  typhoid  and  malaria,  has  geographical  distribution  in  the 
State  anything  to  do  with  it. 

It  is  probable  that  more  are  reaching  the  later  age-periods  when 
deaths  are  more  frequent,  since  the  industry  is  not,  in  its  present  dimen- 
sions, more  than  a  generation  old  in  Illinois.     It  is  probable  also  that  a 


393 

change  in  racial  composition  with  a  greater  percentage  of  foreigners  is 
a  factor.  It  is  more  than  likely  that  greater  congestion  of  population 
and  its  attendant  evils,  without  a  corresponding  increase  in  health  super- 
vision of  housing  and  living  conditions  are  potent  and  basic  factors. 

The  death  rate  of  Illinois  coal  miners  (Table  III)  when  compared 
with  that  of  the  entire  United  States  Registration  Area  (Mortality 
Statistics,  p.  19,  1916)  is  directly  excessive  for  the  following  afflictions: 
Typhoid  fever,  30.8  vs.  13.3;  Cirrhosis  of  liver,  17.6  vs.  12.3;  Suicide, 
31.9  vs.  14.2;  and  Violence  398.2  vs.  90.9. 

VI.    HOW    MINERS    COPE    WITH    SICKNESS   AND    DEATH    HAZARDS. 

In  many  industries  the  management  has  taken  a  leading  part  in  the 
organization  of  sick  and  benevolent  associations  and  similar  institutions. 
Thib  has,  however,  not  been  the  case  in  the  mining  industry  of  Illinois. 
Though  some  thought  has  been  given  the  matter,  very  little  has  been 
done  by  the  operators.  No  doubt  this  is  closely  connected  with  the  fact 
that  the  miners  have  been  thoroughly  organized  and  in  better  position 
than  most  workingmen  to  make  organized  provision  for  themselves. 
However  this  may  be,  in  reporting  on  organized  aid  the  important  details 
relate  to  what  the  unions  are  doing  and  to  the  provision  made  by  fraternal 
orders  and  the  foreign  societies  in  which  the  miners  may  have  mem- 
bership. 

Some  years  ago  the  State  organization  of  the  United  Mine  Workers 
planned  to  pay  disability  benefits  in  case  of  sickness  or  accident  as  well 
as  to  provide  death  benefits.  It  was  felt,  however,  that  with  the  entire 
expense  resting  upon  the  workmen,  the  dues  required  would  be  so  heavy 
as  to  create  dissatisfaction  and  the  plan  was  given  up.  Except  for  the 
death  benefit  of  $250  paid  by  the  State  organization,  any  provision  made 
by  the  miners'  organization  is  through  the  local  union. 

Whether  or  not  organized  provision  by  the  local  union  is  found, 
depends  very  largely  upon  (1)  the  size  of  the  working  force  in  the  mine 
or  mines;  (2)  the  location  of  the  mine  in  respect  to  towns  and  cities; 
(3)  the  racial  composition  of  the  membership  of  the  local;  and  (4)  the 
attitude  of  the  union  officials.  Where  only  a  few  men  are  employed  and 
a  benevolent  association  is  found  in  the  community,  the  local  likely  does 
nothing  in  the  way  of  providing  disability  benefits.  Where  the  mine 
or  mines  are  located  in  a  populous  community,  so  many  of  the  miners 
may  belong  to  fraternal  orders  and  foreign  societies,  that  the  need  for 
provision  by  the  local  is  lessened,  and  if  made,  is  seriously  interfered 
with.  Again,  where  a  majority  of  the  miners  are  foreigners,  most  of 
them  have  show^n  a  preference  for  membership  in  the  foreign  societies, 
which  besides  paying  sick  and  burial  benefits,  are  more  or  less  religious 
in  aspect,  and  other  organizations  find  it  difficult  to  gain  a  foothold. 
Finally,  where  a  local  union  does  organize  a  disability  fund  or  association, 
it  is  usually  optional  with  its  members  whether  or  not  they  shall  join, 
and  a  considerable  percentage  of  the  men  may  remain  outside  of  it.  To 
take  an  extreme  case,  a  local  was  found  with  1,714  members,  only  220  of 
whom  belonged  to  the  benefit  association  affiliated  with  it.     It  should 


394 

be  said  however,  that  reports  from  38  other  locals  with  a  total  member- 
ship of  13,805  showed  a  total  of  13,554  in  the  benefit  funds  maintained 

by  them.  '  .  i    .    .         x- 

In  the  various  districts  the  following  general  information  was 
secured  relating  to  the  extent  to  which  sick  benefit  associations  are  main- 
tained by  the  local  unions : 

District  I :  Very  few  locals  have  sick  benefit  societies. 

District  II,  III,  VII,  and  VIII:  A  considerable  number  of  the 
locals  have  such  associations. 

District  IV:  About  one-fourth  of  the  locals  have  such  associations 
but  the  number  was  reported  as  decreasing. 

District  V :  About  half  of  the  locals  have  such  associations. 

District  VI,  IX,  X,  XI,  and  XII :  Most  locals  have  such  associations. 

The  Commission  received  replies  to  a  questionnaire  from  123  of  the 
305  miners'  locals  in  the  State.  The  summarized  results  indicate  foughly 
to  what  extent  they  have  made  provision  for  sickness  and  death  benefits. 

Of  the  123  locals  reporting,  37  had  made  regular  provision  for  the 
payment  of  sick-benefits  in  stipulated  sums  per  week;  15  levied  assess- 
ments upon  their  members  to  assist  those  in  need;  19  reported  that  they 
"passed  the  hat"  to  assist  needy  members ;  while  52  reported  that  nothing 
was  done  by  the  union  as  such.  The  number  of  members  in  the  37  locals 
was  13,670;  in  the  15  locals  5,868;  in  19  locals  "passing  the  hat,''  4,305. 
The  52  locals  reporting  that  nothing  was  done  by  the  union  as  such,  had 
a  combined  membership  of  16,937.  The  standards  adopted  by  the  37 
locals  with  definitely  organized  benefit  systems,  varied  greatly.  Seven 
had  no  waiting  period  whatever;  1  a  waiting  period  of  less  than  7  days; 
2  a  waiting  period  of  7  but  less  than  14  days ;  5  a  waiting  period  of  14 
days;  3  a  waiting  period  of  more  than  21  bijt  not  to  exceed  30  days. 
The  number  of  consecutive  weeks  for  which  benefits  were  paid  was  be- 
tween 5  and  8  in  five  cases;  9  and  12  in  five  cases;  13  in  ten  cases;  14  to 
25  in  ten  cases;  and  27  or  more  in  five  cases.  Taking  the  maximum 
number  of  weeks  in  the  year  for  which  a  member  might  draw  benefits, 
it  was  between  5  and  8  in  one  case;  9  and  12  in  four  cases;  14  weeks  in 
six  cases;  between  15  and  25  weeks  in  thirteen  cases;  and  52  weeks  in 
nine  cases.  The  other  locals  did  not  report  definitely  on  this  point. 
The  benefit  paid  was  not  to  exceed  $4  per  week  in  three  cases;  was  $5  in 
twenty- three  cases;  $6  in  six  cases;  $7  in  two  cases,  and  $8  in  the  other 
case  where  information  was  furnished. 

The  State  organization  pays  a  death  benefit  of  $250  in  case  of  the 
death  of  a  miner  himself.  To  this  the  locals  frequently  add  a  second 
sum  and  possibly  pay  benefits  in  cases  of  death  of  wife  or  other  de- 
pendent. There  are  305  locals  in  the  State  with  a  membership  of  a 
little  more  than  90,000.  Usable  returns  were  obtained  from  123  of  these 
locals  with  a  combined  membership  of  40,780.  Of  these  123,  eighty-six 
with  a  membership  of  30,660,  added  something  to  the  State  death  benefit. 
The  remaining  37  with  a  membership  of  10,120,  did  not.  Of  those 
paying  an  additional  benefit  in  case  of  death  of  member,  1  paid  a  benefit 
of  $25;  11  a  benefit  of  $50;  9  a  benefit  of  $75;  27  a  benefit  of  $100  or 
$125;  15  a  benefit  of  $150  or  $175;  7  a  benefit  of  $200  to  $399;  and  6 


395 

a  benefit  of  $500  or  more.  Fourteen^  all  told,  paid  a  benefit  in  case  of 
death  of  wife  of  member.  In  two  cases  this  was  from  $50  to  $74;  in 
three  cases  from  $75  to  $99 ;  in  seven  cases  $100  to  $149 ;  in  one  $300 
to  $399;  in  one  $500  or  more.  Eleven  of  these  locals  paid  benefits  in 
the  case  of  the  death  of  children  also.  In  one  of  these  the  benefit  was 
less  than  $25 ;  in  four  from  $25  to  $49 ;  in  six  from  $50  to  $74. 

Whether  or  not  this  union  provision  is  becoming  more  or  less  ex- 
tensive it  is  impossible  to  say.  Complete  records  are  not  available  and 
the  statements  made  by  those  more  or  less  familiar  with  the  matter  are 
contradictory.  New  associations  have  been  organized  here  and  there, 
while  many  of  those  organized  have  been  abandoned  after  a  time.  The 
new  ones  have  been  organized  to  meet  a  need  distinctly  felt  and  to  get 
rid  of  the  irregular  assessments  and  ^^passing  the  hat."  Some  have  been 
abandoned  because  of  the  decreased  need  for  them  when  compulsory 
compensation  for  accidents  was  adopted,  a  few  because  the  dues  re- 
quired were  felt  to  be  too  heavy^  and  still  others  because  of  the 
"bother"  they  gave  in  administration. 

This  partial,  unstandardized  provision  made  by  the  local  unions 
is  supplemented  by  or  is  supplementary  to  the  insurance  provided  by 
fraternal  orders,  foreign  societies,  and  insurance  companies. 

It  was  found  that  the  fraternal  orders  are  well  represented  in  the 
mining  districts.  It  could  not  be  said  that  any  one  of  these  is  univers- 
ally strong  among  the  miners.  At  one  place  it  is  the  "Odd  Fellows"  who 
predominate  and  at  another  the  "Eed  Men"  or  the  "Moose,"  etc.  The 
per  cent  of  miners  carrying  sick  benefits  in  such  associations  could  not  be 
accurately  obtained  in  this  inquiry,  but  many  whose  opinions  were  asked 
put  it  in  the  neighborhood  of  50  per  cent. 

Separate  and  distinct  from  these  English-speaking  fraternals  are  the 
societies  among  the  "foreign  classes."  It  was  the  universal  statement  that 
practically  all  foreigners  belonged  to  some  one  or  more  of  these  orders. 
They  seem  more  appreciative  of  insurance  protection  than  the  native 
Americans.  Many  of  them  have  received  their  initiation  into  community 
insurance  schemes  abroad  in  the  various  countries  from  which  they  have 
come. 

In  two  or  three  districts  it  was  found  that  a  few  insurance  companies 
were  making  a  special  effort  to  write  sickness  insurance  among  miners 
There  was  nothing  extensive  in  this  direction.  Some  of  the  companies 
were  making  a  feature  of  carrying  miners  at  no  greater  risk  than  the 
balance  of  the  populace. 

The  usual  forms  of  industrial  insurance  were  everywhere  present 
in  the  mining  districts,  through  which  children,  in  particular,  are  covered 
for  funeral  benefits. 

Summarizing,  it  may  be  said  that  through  the  union  benefit  asso- 
ciation, the  fraternal  order,  the  foreign  society,  and  the  insurance  com- 
panies writing  disability  contracts,  the  majority  of  the  miners  are  in- 
sured against  sickness,  acceptably  or  unacceptably  as  the  case  maye  be. 
In  some  localities  nearly  all  have  disability  insurance;  in  few  cases  does 
the  percentage  fall  below  fifty.  It  may  be  added,  also,  that  many  of  the 
miners,  perhaps  the  foreigners  more  than  the  others,  carry  sickness  in- 


396 

suraiice  in  several  organizations,  so  that  the  statement  was  frequently 
made  that  a  man  while  sick  might  draw  more  money  in  sick  benefits 
collected  than  he  did  while  well  and  at  work.  All  miners  are  entitled 
to  death  benefits  from  one  or  more  sources.  Their  dependents  are 
usualy  provided  with  burial  insurance. 

The  above  has  been  limited  to  pecuniary  benefits  in  cases  of  sickness 
and  death.  Nothing  has  been  said  concerning  provision  for  medical 
and  hospital  care  for  seldom  do  the  organizations  providing  insurance 
provide  anything  more  than  cash  benefits.  However,  some  exceptional 
cases  are  noted  in  the  next  section  of  this  report  which  relates  to  com- 
munity medical  facilities. 

VII.    COMMUNITY    MEDICAL    FACILITIES. 

First  wid. — By  State  Law,  all  mines  of  certain  size  are  required  to 
have  at  least  a  minor  first-aid  equipment,  consisting  of  litter,  blankets, 
kit  of  bandages,  simple  instruments,  antiseptics,  etc.  Furthermore,  all 
mine  managers  (mine  bosses  and,  as  a  rule,  mine  examiners,  are  required 
to  have  first-aid  training  for  which  they  receive  a  license.  Some  large 
mines  have  first-aid  teams.  Occasionally  a  separate  first-aid  room  with 
operating  table  and  other  appliances  is  at  hand,  and  sometimes  an 
emergency  hospital  room  or  building  is  found  near  the  tipple.  Some 
companies  own  ambulances.  "Safety  First"  is  always  to  the  fore  in 
mines.  A  refuge  room  or  space  is  required  by  law  near  the  foot  of  the 
hoisting  shaft.  Manholes  or  refuge  places  on  haulage  roads  occur  every 
60  feet  and  must  be  on  the  side  opposite  the  trolley  wire  on  motor  haul- 
age roads.  At  Marion,  the  miners'  locals  own  an  ambulance  and  main- 
tain an  undertaking  establishment  for  their  own  use. 

Sick  quarterTs. — ^Men  hurt  or  taken  suddenly  sick  in  the  mine  are 
rushed  to  the  surface — usually  to  the  engine  room,  the  wash-house  or 
the  mine  office.  In  the  meantime  the  physician  who  is  called  by  tele- 
phone has  usually  arrived.  After  first-aid  attention  is  given  the  afflicted 
man  is  taken  home  where  he  goes  under  the  supervision  of  the  physician 
of  his  choice. 

Control  of  epidemics. — ^In  the  presence  of  an  epidemic  the  mining 
company  and  the  local  union  follow  the  policy  of  non-interference,  leav- 
ing it  quite  entirely  to  the  supervision  of  whatever  local  health  authority 
is  at  hand.  Insistence  on  vaccination  against  smallpox  has  been  at- 
tempted at  some  mines.     Closing  of  the  wash-house  may  also  be  ordered. 

Stability  of  medical  practice. — Inquiry  showed  that  physicians  in 
mining  districts  are  just  as  likely  to  locate  permanently,  perhaps  for 
life,  as  they  are  in  other  localities.  They  appeared  to  get  less  oppor- 
tunity for  vacation  periods  than  elsewhere.  Physicians  were  practically 
always  native  Americans. 

•Contract  practice. — As  is  well  known,  contract  practice  for  so-much 
per-man-per-month  is  looked  upon  with  disfavor  by  county  medical 
societies.  This  feeling  seems  to  be  shared  by  the  local  unions  also.  As 
a  result  of  this  disfavor,  contract  practice  is  less  extensively  found  than 
formerly  in  the  mining  districts.  Of  the  53  physicians  interviewed, 
three  maintained  a  contract  practice  on  the  basis  of  $1  per  month  per 


397 

family,  or  50  cents  per  month  in  the  case  of  single  men.  At  one  place 
where  a  large  per  cent  of  negroes  are  employed,  the  plan  seemed  to  be 
running  very  smoothly,  due  largely  to  the  energy  of  the  colored  phy- 
sician himself  and  the  support  he  received  from  the  operating  company. 

Prevailing  fee-rates. — The  rates  charged  miners  were  the  same  as 
for  other  inhabitants  in  each  district.  In  some  smaller  southern  towns 
fee-rates  were  low  but  in  general  they  vary  little  from  one  end  of  the 
State  to  the  other.  The  usual  fees  were:  for  calls  at  the  house,  $2; 
night  calls,  $3  and  up;  office  calls,  $1  and  up,  usually  with  medicine 
included;  milage,  50  cents  a  mile  after  the  first  mile,  or,  certain  rates 
to  certain  places;  confinement  cases  from  $15  up.  Whether  the  phy- 
sician looked  to  the  operating  company,  the  insurance  company  or  the 
individual,  remuneration  was  quite  invariably  upon  the  merit  basis — so 
much  for  so  much  service  rendered.  For  some  forms  of  surgical  work  a 
fee  schedule  previously  agreed  upon  with  an  insurance  company  was 
followed.  Inquiry  seemed  to  show  that  there  was  little  haggling  about 
the  question  of  fees  in  State  compensation  cases  or  complaint  about 
securing  reasonable  payment  of  bills  from  insurance  companies. 

Mileage  covered  by  physicians. — The  mining  physician  covers  a 
radius  of  about  five  miles  in  his  practice.  Variations  depend  upon  rail- 
road facilities  and  other  local  conditions. 

Ratio  of  physicians  to  population. — The  results  of  inquiry  into  this 
point  were  tabulated  and  showed  that  in  normal  times  and  considering 
the  proximity  of  many  mining  centers  to  large  cities,  there  is  no  dearth 
of  licensed  practitioners  at  hand  and  that  (with  one  or  two  places  ex- 
cepted) the  ratio  of  physicians  to  the  population  is  adequate  to  the 
present  demand  for  their  services.  The  actual  ratio  is,  however,  not 
quite  so  favorable  as  one  physician  to  every  739  of  the  population  as 
reported  (1918)  for  the  entire  United  States.  Proximity  to  neighbor- 
ing large  cities  usually  compensated  for  dearth  of  physicians  locally. 

Non-medical  practitioners. — Except  in  the  larger  mining  cities 
there  was  almost  an  entire  absence  of  osteopaths,  chiropractors,  neuro- 
paths, optometrists,  mental  and  faith  healers,  etc.  Licensed  midwives 
were  practically  absent.  Women  practicing  midwifery  unlicensed,  es- 
pecially in  foreign  communities^  were  mentioned  here  and  there.  How- 
ever, foreigners  were  invariably  desirous  of  getting  a  "good  doctor"  in 
maternity  cases.  With  some  instruction,  many  of  these  women  could 
be  trained  to  be  of  great  practical  service  to  busy  mining  physicians, 
although  but  few  of  them  could  meet  the  educational  requirements  of 
the  law  for  a  licensed  midwife. 

Nurses  and  nursing. — The  trained  nurse  is  almost  an  unknown 
person  in  practically  all  mining  communities  even  in  non-war  times. 
Whole  counties  were  reported  as  without  the  services  of  a  trained  nurse, 
public  or  private.  The  number  of  practical  nurses  was  found  to  be  very 
limited  also,  but  most  physicians  explained  that  there  were  two  or  three 
"handy"  women  in  the  vicinity  to  help  out.  Many  persons  expressed 
the  opinion  that  a  community  organization  to  assume  part  or  all  of  the 
cost  of  a  trained  nurse^s  services  would  be  advisable. 


398 

Diagnostic  facilities. — While  an  X-ray  was  most  apt  to  be  readily 
available,  still  for  such  a  convenience,  as  well  as  for  most  laboratory  work, 
recourse  was  usually  had  to  large  cities.  Such  methods  were  reasonably 
prompt,  but  some  physicians  said  that  much  more  scientific  medicine 
would  be  practiced  were  diagnostic  facilities  more  convenient. 

Hospitals.— The  proximity  aad  availability  of  hospitals  to  mining 
communities  varied  greatly.  The  accessibility  of  a  hospital  means  much 
more  to  the  physician  and  the  patient's  family  and  friends  than  it  does 
to  the  patient,  who  may  be  taken  easily  enough  to  a  hospital  fifty  miles 
or  more  away.  But  physicians  cannot  afford  the  time  or  the  expense 
of  trips  to  distant  hospitals.  Consequently,  where  hospitals  are  in  the 
mining  community  itself,  the  extent  of  their  use  by  coal  miners  and  their 
families  is  much  greater  than  when  they  are  at  a  distance,  and  much 
of  the  physician's  time  is  saved.  It  was  found  that  miners  rarely  resort 
to  hospitals  for  treatment,  and  members  of  their  families  even  less  so. 
The  foreigner  seems  to  appreciate  the  advantages  of  hospitalization  more 
than  does  the  American.  • 

A  cooperative  miners'  hospital  is  maintained  by  the  various  miners' 
locals  at  West  Frankfort,  in  Franklin  County,  which  is  rather  unique 
because  of  the  fact  that  it  is  practically  the  only  example  of  workmen's 
efforts  in  this  direction  in  the  country.  It  is  a  first-class  hospital, 
managed  by  a  board  of  trustees  from  among  the  miners,  with  an  orofan- 
ized  physician's  and  nursing  staff.  It  is  a  busy  place  and  receives  both 
miners  and  members  of  miners'  families,  the  hospital  expenses  beinor  xnet 
by  tl^e  local  unions.  The  only  strictly  mining  company  hospital  was 
reported  at  Zeigler  and  was  also  visited.  It  is  thorousrhlv  equipped  and 
manned,  the  hospital's  expenses  being  met  principally  by  the  operating 
company. 

Organized  aid  and  the  physician. — The  effects  of  the  sick  benefit 
association  in  relation  to  the  physician  is  worthy  of  comment.  Mem- 
bers of  these  associations,  as  well  as  of  lodges  and  fraternals  furnishing 
sick  benefits,  usually  expect  most  of  the  fee  for  medical  services  to  be 
met  by  the  weekly  cash  benefit.  In  order  to  enable  the  afflicted  one  to 
secure  this  benefit,  the  physician  fills  out  a  certificate  of  illness.  These 
financial  arrangements  were  commented  upon  as  often  uninviting.  Where 
a  miner  belongs  to  several  lodges  or  societies,  he  presents  several  cer- 
tificates, usually  each  week.  Sometimes  health  insurance  companies  and 
some  of  the  fraternal  societies  require  extensive  blanks  to  be  filled  out. 
In  practically  all  cases,  physicians  stated  they  made  no  charge  for  this 
service,  and  that  they  did  the  same  because  the  patient  was  in  their 
regular  clientele  and  that  they  could  not  well  do  otherrvqse.  A  couple 
of  physicians  stated  that  they  charged  from  50  cents  to  $1  for  such 
service.  Nearlv  all  physicians  interviewed  complained  that  the  multi- 
plicitv  of  certificates  to  be  filled  out  s^ratis  was  the  '^ane  of  their  exist- 
ence." Two  physicians  in  partnership  in  a  busy  mining  community 
stated  that  between  them  at  least  eight  hours  per  week  were  spent  in 
this  filling  out  of  sick  benefit  certificates. 

Many  physicians  commented  also  upon  the  evident  attempts  at 
malingering  which  were  associated  with  collections  from  benefit  societies, 


399 

» 

and  particularly  where  a  workman  was  over-insured  by  carr}dng  policies 
in  several  societies.  Most  physicians  stated  that  they  would  like  to  see 
some  other  system  adopted  for  the  present  sickness  insurance  relation- 
ship. For  instance,  the  submission  of  bills  directly  to  the  benefit  so- 
ciety and  the  dealing  with  a  limited  number  of  societies  per  patient 
were  mentioned.  Xone,  however,  attempted  to  devise  a  workable  plan. 
The  physician  feels  safer  as  to  his  own  remuneration  when  he  is  dealing 
with  an  organized  body,  such  as  a  lodge  or  society,  than  when  he  is  deal- 
ing directly  with  many  of  the  patients  who  seek  his  services  in  mining 
communities. 

Economics  of  medical  practice. — There  was  no  evidence  to  the  effect 
that  miners  are  not  as  good  pay  as  any  other  class,  considering  race, 
locality  and  civil  state.  The  general  average  of  collections  was  about 
65  per  cent  in  nonnal  times,  and  only  somewhat  better  at  present. 
Some  physicians  reported  their  collections  as  low  as  50  per  cent,  but 
stated  that  they  were  not  good  collectors.  Others,  who  had  more  business 
system,  claimed  collections  as  high  as  90  to  95  per  cent.  Collections 
were  better  in  isolated  localities,  as  a  rule.  An  interesting  observation 
was  made  by  a  prominent  physician  in  LaSalle,  who  stated  that  prac- 
tically all  physicians^  bills  there  and  in  that  vicinity  were  good  because 
it  was  the  result  of  twenty  years'  education  of  the  populace  to  look  upon 
them  the  same  as  upon  grocery  bills  and  to  pay  them  promptly.  In  one 
place  the  business  men  of  the  town,  including  the  physicians,  kept  a 
confidential  list  of  persons,  classified  as  good,  average  and  bad  bill  payers. 

Increased  labor  turn-over  at  the  mines  was  blamed  for  many  fail- 
ures to  collect.  In  many  communities  it  was  stated  that  slow  pay  was 
a  bad  feature,  and  particularly  so  in  normal  times  when  the  mines  were 
idle  for  a  number  of  weeks  or  months  each  year.  One  physician  in 
Saline  County  said  he  always  got  an  order  on  a  man's  pay  before  he 
agreed  to  attend  him  or  his  family.  Accident  compensation  has  re- 
sulted in  better  collections  and  more  prompt  demand  in  the  case  of 
treatments  for  injuries.  Multi-treatments,  or  the  practice  of  calling  one 
physician  after  another,  or  perhaps  having  two  or  more  at  the  same  time, 
each  unknown  to  the  other,  was  mentioned  as  frequent  in  communities 
of  foreigners.  All  physicians  had  some  charity  patients,  the  number 
increasing  in  hard  times.  Chronic  invalidism  from  sickness  was  not 
above  the  average.  Many  maimed  indi^dduals  are  to  be  seen  in  all  large 
mining  towns. 

Physicians  emphasized  the  great  extent  to  which  quackery  and  the 
practice  of  charlatans  prevailed.  Here  and  there  counter-prescribing  in 
which  the  druggist  prescribes  something  instead  of  sending  the  afflicted 
one  to  a  physician  was  mentioned.  Also  the  fact  that  physicians'  pre- 
scriptions were  filled  repeatedly  without  the  physician's  sanction,  and 
perhaps  for  different  sick  persons.  The  old-time  street  medicine  vendor 
has  quite  disappeared  from  most  of  the  mining  districts  of  the  State. 
However,  the  practice  of  self-treatment,  which  embodies  self-diagnosis, 
has  undoubtedly  extended,  and  unquestionably  increases  the  spread  of 
communicable  diseases  and  the  incidence  and  severity  of  all  afflictions. 
It  is  especially  fostered  in  mining  districts  by  various  types  of  nostrum 


400 

• 

propaganda,  in  which  full  use  is  madft  of  the  advertising  columns  of 
newspapers,  billboards,  and  the  mails.  Its  most  important  cause  is  un- 
questionably lack  of  ready  funds  with  which  to  pay  for  legitimate  treat- 
ment. Another  important  cause  is  that  the  treatment  is  felt  to  be  too 
expensive. 

VIII.    GENERAL    SUMMARY. 

By  means  of  direct  field  survey,  in  which  fifty-six  mines  and  their 
associated  communities  in  the  twelve  coal  districts  of  the  State  were 
visited,  and  by  means  of  questionnaires,  the  status  of  the  health  of  Illi- 
nois coal  miners  was  invesigated  during  the  summer  of  1918.  Soft  coal 
only  is  mined.  The  coal  mining  industry  in  the  State  is  steadily  in- 
creasing and  employs  over  90,000  workmen. 

Working  conditions  in  Illinois  coal  mines  are  as  good  as,  if  not 
above  the  average  found  in  most  industries.  While  the  mines  are  of 
deep  character,  they  are  dry,  as  a  rule,  with  cool,  even,  and  invigorating 
temperatures  and  the  State  mining  inspection  system  succeeds  generally 
in  maintaining  a  good  quality  of  atmosphere  in  the  mines.  The  laws 
and  regulations  when  followed  appear  to  be  adequate,  although,  un- 
doubtedly, minor  amendments  are  constantly  advisable.  Practically  all 
mines  have  wash-houses  more  or  less  adequate.  A  glaring  omission  is 
absence  of  latrines  for  workers  about  the  top  at  a  majority  of  the  mines. 
A  serious,  common  fault  is  lack  of  examination  of  drinking  water 
supplies  which  miners  use. 

There  is  practically  no  overtime  even  in  the  present  stress.  The 
eight-hour  day  prevails. 

All  coal  miners  belong  to  the  United  Mine  Workers  of  America. 
Foreigners,  principally  Italians  and  Eastern  Europeans,  predominate. 
But  6.1  per  cent  of  13,889  employees  in  49  mines  visited  were  found  to 
be  over  60  years  of  age.  Wages  are  good  but,  in  normal  times  many 
mines  are  idle  for  weeks  and  months  each  year  because  of  the  uneven 
demand  for  coal. 

Dust  appears  to  be  the  chief  health  hazard  which  remains  for  the 
Illinois  coal  miner  to-day.  Physical  strain,  any  evil  effects  of  which 
could  be  frequently  avoided  if  men  were  selected  for  their  jobs  by  physical 
examinations,  causes  a  train  of  musculo-osseous  and  possibly  circulatory 
afflictions  of  incapacitating  character. 

Housing  conditions,  community  neglect,  bad  forms  of  recreational 
hygiene  and  especially  alcoholism,  undoubtedly  constitute  the  chief 
causes  of  most  sickness.  This  whole  situation^  is  due  largely  to  the 
inadequacy  of  community  health  organization  and  prophylactic  measures 
against  diseases. 

Rheumatism,  asthmatic  afflictions  and  alcoholism  constitute  the 
chief  forms  of  sickness.  With  the  exception  of  tuberculosis,  venereal 
diseases  and  possibly  pneumonia,  all  common  afflictions  are  of  usual  fre- 
quency in  the  practices  of  physicians  in  mining  districts.  Mortality 
statistics,  on  the  other  hand,  show  tuberculosis  is  more  frequent  than 
physicians  suppose  and  that  pneumonia  is  really  excessive  when  compared 
to  occupied  males  in  general.     Several  diseases  supposedly  of  industrial 


401 

character  among  miners,  such  as  hookworm,  nystagmus,  and  lockjaw  were 
found  to  be  non-existent. 

Mortality  statistics  show  a  gradually  increasing  annual  death  rate, 
beginning  with  1,003  per  100,000  employed  in  1912  (fiscal  year)  and 
rising  to  1,185  for  the  first  half  of  1918.  About  two-fifths  of  all  deaths 
are  due  to  external  causes  (violence  and  mishaps)  and,  consequently,  the 
prevalence  of  any  other  afflictions  such  as  tuberculosis  are  overshadowed, 
when  viewed  from  the  cause  of  death.  However,  as  compared  to  the 
United  States  Registration  Area  for  1916,  the  Illinois  coal  miner's  death 
rate  is  directly  and  very  decidedly  excessive  from  typhoid  fever,  cirrhosis 
of  liver,  suicide,  and  violence.  Illinois  miners  compare  favorably  with 
miners  and  quarrymen  in  the  Registration  Area  (1909)  as  regards 
deaths  from  various  causes.  Geographical  distribution  in  the  State 
appears  to  have  little  relationship  to  death  rates,  except  for  malaria  and 
typhoid — both  pronounced  in  the  south.  The  cause  for  the  increasing 
death  rate  is  not  clear. 

Miners  as  a  body,  or  as  groups,  cope  with  sickness  and  death 
hazards  in  many  different  ways,  with  greatly  varying  success,  and  with 
no  very  efficient  methods.  All  sorts  of  schemes  exist,  depending  upon 
localit}^,  race,  size  of  mining  district,  etc.  Many  miners'  local  unions 
maintain  optional  sick  benefit  societies,  but  all  manner  of  modes  of  pro- 
cedure exist.  Many  of  them  are  on  the  decline,  due  largely  to  the  effects 
of  State  compensation  for  accidents.  The  miners'  State  organization 
pays  a  death  benefit  of  $250  in  case  of  the  death  of  a  miner.  To  this 
the  locals  frequently  add  a  second  sum.  Occasionally,  members  of 
miners'  families  are  included.  The  various  national  fraternal  orders 
have  strong  representation  in  mining  districts.  Miners  often  belong  to 
several  and  may  derive  over-insurance  therefrom.  No  operating  com- 
panies take  a  direct  interest  in  benefit  societies  as  with  some  other  in- 
dustries. ]N'o  insurance  companies  provide  group  insurance  covering 
sickness  for  the  employees  of  a  mine.  Industrial  insurance  by  private 
companies,  providing  a  small  burial  fund  for  children,  is  extensive. 

Community  medical  facilities  are  no  more  than  fair.  First-aid 
provisions  at  mines  are  good.  Hospital  facilities  are  very  scarce.  Local 
health  administration  is  in  a  very  bad  way.  Prophylaxis  and  preventive 
medicine  is  hardly  known  in  most  districts.  There  is  great  need  of  in- 
structions, also,  in  the  fundamental  facts  of  personal  hygiene.  Most 
dissipations  were  found  to  be  the  result  of  a  misconception  of  what 
constitutes  recreation. 

Medical  practice  in  mining  centers  is  maintained  b)^  a  set  of  steady, 
hard-working  native  American  physicians,  very  few  of  whom  engage  in 
contract  practice.  Fee-rates  for  miners  are  the  same  as  obtain  for  others, 
which  rates  do  not  vary  much  from  one  end  of  the  State  to  the  other, 
with  the  exception  of  a  few  smaller  towns  in  the  southern  part.  With 
the  present  demand  for  their  services,  there  are  enough  physicians  to  the 
population  in  mining  centers,  especially  in  normal  times.  Trained 
nurses,  and,  in  fact,  practical  nurses,  are  practically  unknown  persons 
in  mining  districts.     Diagnostic  facilities  are  meagre  and  most  labora- 

—26  H  I 


402 

tory  work  is  sent  to  larger  cities.  More  scientific  medicine  would  be 
practiced  in  these  districts  were  more  laboratory  and  hospital  facilities 
at  hand. 

Physicians  are  not  satisfied  with  the  present  relations  which,  they  have 
with  persons  insured  in  various  benefit  societies  for  whom  the  physician 
must  certify  as  to  sickness  before  cash  benefits  ^re  forthcoming  and  before 
the  physician  can  receive  his  remuneration.  Malingering  is  also  a  con- 
siderable feature,  and  many  physicians  were  of  the  opinion  that  where  an 
individual  has  a  sick  benefit  in  a  lodge  or  society,  an  improvement  in  the 
situation  might  be  made  by  submitting  bills  directly  to  the  society  instead 
of  to  the  jiatient;  also,  that  the  number  of  societies  in  which  a  workman 
may  insure  against  sickness  could  be  limited  to  great  advantage. 

In  normal  times  miners,  do  not  work  steadily  throughout  the  year 
in  most  districts,  so  that  physicians  have  periods  of  decreased  collections, 
although  the  miner  pays  as  well  as  any  other  industrial  class.  Nostrum 
and  quackery  propaganda  flourishes  in  mining  districts.  There  is  a  very 
limited  number  however,  of  non-medical  practitioners  belonging  to  the 
various  cults. 

There  is  much  room  for  improvement.  To  a  great  extent  it  involves 
education  in  ideals.  Some  organized  corrective  efforts  are  undoubtedly 
advisable.  Stress  should  certainly  be  laid  on  the  application  of  means 
to  prevent  sickness  as  well  as  extension  of  means  to  cope  with  the  sick- 
ness which  exists. 


403 


SPECIAL  REPORT  VI.     INSURANCE  BY  CASUALTY  COM- 
PANIES  AND  ASSESSMENT  ASSOCIATIONS. 

(By  W.  M.  Duffus.) 


[Note  hy  the  Secretary. — A  very  important  part  of  the  Commission's  work  was 
to  ascertain  as  fully  as  possible  the  extent  and  character  of  existing  health  in- 
surance in  Illinois.  The  Investigations  made  in  this  connection  related  to  insur- 
ance in  establishment  funds,  labor  organizations,  fraternal  societies,  independent 
foreign  societies,  and  the  many  types  of  insurance  companies  and  associations. 
A  large  part  of  this  work  was  done  by  Professor  W.  M,  DufCus,  on  leave  from, 
the  University  of  Kansas  where  he  is  Associate  Professor  of  Economics.  Professor 
Duffus  has  drafted  the  four  special  reports  which  immediately  follow,  relating, 
respectively,  to  Insurance  by  Casualty  Companies  and  Assessment  Associations, 
Fraternal  Life  and  Disabilty  Insurance,  Industrial  Life  Insurance,  and  Group  Life 
and  Group  Disability  Insurance.] 

PART  I.    INSURANCE  BY  CASUALTY  COMPANIES. 

(1)   Introductory. 

The  laws  of  the  State  of  Illinois  authorize  the  organization  of 
casualty  insurance  corporations.  These  corporations  may  restrict  them- 
selves in  the  purpose  of  their  organization  to  "insuring  any  person 
against  bodily  injury,  disablement  or  death  resulting  from  accident,  and 
providing  benefits  for  disability  caused  by  disease/^  or  may  also  write 
other  kinds  of  insurance  such  as  fidelity  and  surety,  workmen's  com- 
pensation, burglary,  plate  glass,  and  credit  insurance.  The  laws  permit 
the  admission  into  Illinois  of  similar  corporations  organized  under  the 
laws  of  other  states  or  the  laws  of  foreign  governments.^  Stock  life 
insurance  companies,  upon  compliance  with  certain  conditions,  may 
engage  in  the  health  and  accident  business.  Of  the  73  "casualty  com- 
panies" possessing  licenses  to  transact  a  health  and  accident  insurance 
business  in  Illinois  on  December  31,  1917,  25  were  authorized  to  transact 
this  kind  of  business  only  while  48  were  writing  one  or  more  other  lines 
of  insurance.  Eight  of  the  companies  were  Illinois  corporations,  57  were 
corporations  of  other  states  and  8  were  corporations  of  foreign  govern- 
ments.^ Casualty  companies  may  be  organized  in  Illinois  on  either  the 
stock  or  the  mutual  plan.^  Two  of  the  Illinois  companies  were  mutual 
companies ;  the  six  remaining  Illinois  companies  and  all  of  the  companies 
of  the  other  states  and  foreign  governments  were  stock  companies.* 

Information  concerning  the  health  and  accident  insurance  business 
conducted  by  casualty  companies  in  Illinois  was  obtained  through  a 
questionnaire  sent  directly  to  the  companies  by  the  Insurance  Superin- 

^  Insurance  Laws  of  the  State  of  Illinois,  1917,  compiled  by  the  Department  of 
Trade  and  Commerce  of  the  State  of  Illinois,  Insurance  Division,  Chapter  VII, 
p.   114. 

^  Official  Statement  Showing  the  Financial  Condition  and  Bitsiness  of  the  Mis- 
cellaneous Insurance  Companies  for  the  Year  Ending  December  SI,  by  the  Depart- 
ment of  Trade  and  Commerce  of  the  State  of  Illinois,  Division  of  Insurance. 

^Insurance  Laws  of  the  State  of  Illinois,  1917,  pp.   114-117  and  137-143. 

"iSee  Note  2. 


404 

tendent  acting  in  cooperation  with  this  Commission,  by  correspondence 
and  personal  interviews  with  representatives  of  the  companies  and  from 
the  testimony  of  the  latter  and  of  other  persons  at  the  public  hearings 
held  by  the  Commission.  Considerable  information  was  obtained  also 
from  the  family  studies  described  elsewhere  in  this  report.^ 

Up  to  the  present  time  the  casualty  companies  have  been  of  minor 
importance  in  Illinois  as  carriers  of  health  and  accident  insurance  for 
wage-earners.  It  is  true  that  the  companies  do  carry  a  large  volume 
of  workmen's  compensation  and  employer's  liability  insurance  for  em- 
ployers of  labor  in  Illinois,  but  these  kinds  of  insurance,  notwithstanding 
their  importance  to  the  wage-earners  of  the  State,  cover  only  a  part  of 
the  accident  hazards  and  few  of  the  sickness  hazards  to  which  they  are 
constantly  exposed.  It  is  also  true  that  some  of  the  companies  maintain 
"industrial  departments"  and  have  devised  health  and  accident  policies 
especially  designed  to  meet  the  needs  of  wage-earners  and  that  these  com- 
panies do  most  of  their  business  with  wage-earners.  Policyholders  of 
this  class,  however,  are  in  the  minority  in  the  total  number  of  holders  of 
health  and  accident  policies  issued  by  casualty  companies  in  Illinois. 
For  the  purposes  of  the  present  investigation  the  casualty  companies  are 
more  important  because  of  the  possibilities  for  increased  usefulness  to 
wage-earners  in  the  future  which  the  spokesmen  of  the  companies  allege 
are  found  in  their  plan  of  providing  health  and  accident  insurance  than 
because  of  past  service  and  accomplishment  in  providing  wage-earners 
with  insurance. 

It  is  impossible  to  state  exactly  the  number  of  persons  in  Illinois 
who  carry  health  and  accident  insurance  with  casualty  companies.  The 
companies  are  not  required  by  law  to  report  the  number  of  outstanding 
policies  in  the  State  or  to  report  the  number  of  policyholders  to  the  In- 
surance Superintendent,  and  only  about  one-third  of  the  companies  have 
provided  this  Commission  with  detailed  information  requested  on  this 
particular  point.  Some  of  the  companies  have  reported  that  they  have  no 
records  which  would  give  the  information;  others  that  they  have  been 
unable  to  compile  the  information  because  of  a  shortage  in  office  help  due 
to  war  conditions;  while  a  number  in  returning  the  blanks  sent  them 
have  omitted  the  statement  requested  without  comment.  In  this  re- 
grettable absence  of  complete  statistics  the  Commission  can  only  esti- 
mate the  number  of  health  and  accident  policies  outstanding  against 
casualty  companies  in  Illinois. 

Because  of  the  insufficient  data  obtainable  and  the  variety  and  com- 
plexity of  the  health  and  accident  insurance  policies  which  are  written 
in  Illinois  it  is  difficult  to  make  an  accurate  estimate  of  the  number  in' 
force  in  the  State.  In  fact  it  is  possible  to  make  only  a  rough  guess  at 
the  exact  number.  Estimates  of  the  average  cost  per  year  of  the  health 
and  accident  policies  written  by  casualty  companies  vary  from  $15  to 
$20.®  The  total  amount  collected  by  the  casualty  companies  for  health 
and  accident  insurance  in  Illinois  in  1917  was  $3,489,330.32.^     If  the 

"  See  Part  II,  Special  Report  I. 

'  Report  of  the  Social  Insurance  Commission  of  the  State  of  California,   1917, 
p.  240. 

''Insurance  Report  Illinois,  1917,  Part  III,  pp,  7  and  8. 


405 

$20  estimate  is  accurate  for  Illinois  the  nuniber  of  policies  in  force  in  the 
State  in  1917  was  about  175,000;  if  the  $15  estimate  is  accurate  the  num- 
ber was  about  235,000.  It  seems  desirable  to  estimate  only  the  upper 
limit  of  the  number  of  policies  and  to  err,  if  at  all,  on  the  side  of  over- 
statement rather  than  on  that  of  understatement.  Approaching  the 
matter  in  this  way  and  using  such  data  as  are  available  the  Commission 
has  come  to  the  conclusion  that  the  total  nimiber  of  health  and  accident 
policies  (including  the  combined  health  and  accident  policies  as  well  as 
the  policies  which  provide  health  insurance  or  accident  insurance  only) 
which  were  in  force  against  casualty  companies  in  Illinois  on  December 
31,  1917,  did  not  exceed  250,000.^  The  number  of  policyholders  was, 
of  course,  somewhat  less  because  of  the  fact  that  some  policyholders — how 
many  it  is  impossible  to  ascertain — carry  more  than  one  policy.      • 

The  foregoing  estimate  has  to  do  with  the  number  of  all  persons  of 
all  economic  classes  in  Illinois  who  are  insured  with  casualty  insurance 
companies  against  sickness  and  accident  and  is  not  restricted  to  the  num- 
ber of  wage-earners  so  injured.  In  order  to  get  information  as  to  the 
relative  importance  of  wage-earners  among  the  policyholders  a  question 
was  included  in  the  questionnaire  sent  by  the  Insurance  Superintendent 
to  the  companies  regarding  the  percentages  of  Illinois  policyholders  who 
were  "wage-earners  or  members  of  wage-earning  families."  Answers  of 
scientific  accuracy  were  not  expected  and  were  not  received  but  it  is 
believed  that  the  answers  which  were  received  can  be  relied  upon,  in  the 
aggregate,  to  throw  some  light  on  the  situation. 

A  large  proportion  of  the  health  and  accident  policies  sold  by 
casualty  companies  in  Illinois  are  purchased  by  business  and  professional 
men  and  by  salaried  persons.  Some  companies  confine  their  business 
entirely  to  members  of  these  classes.  Others  accept  wage-earners  as 
policyholders  but  do  not  actively  solicit  their  patronage.  A  few  com- 
panies in  recent  years  have  specialized  chiefiy  in  the  sale  of  health  and 
accident  insurance  to  farmers.  A  number  of  companies,  however,  de- 
pend upon  wage-earners  for  the  greater  part  of  their  business  and  make 
especial  efforts  to  attract  wage-earner  policyholders. 

Returns  of  the  questionnaire  sent  out  by  Insurance  Superintendent 
Potter  were  received  from  44  casualty  companies.  One  of  these  com- 
panies began  business  in  Illinois  in  February,  1918,  and  its  experience  is 
therefore  insufficient  to  serve  as  the  basis  for  any  conclusions.  Of  the 
remaining  43  companies  9  either  made  no  statement  as  to  the  percentages 
of  wage-earners  or  members  of  wage-earning  families  among  thier  policy- 
holders or  reported  that  they  had  no  records  which  would  show  these 
percentages. 

Of  the  34  making  definite  replies  5  stated  that  "none''  or  "practically 
none"  of  their  policyholders  were  members  of  the  wage-earning  class 
while  the  others  reported  various  percentages  of  their  policyholders, 
ranging  from  5  to  100  per  cent,  as  being  of  this  class.     It  would  perhaps 

»It  is  worth  noting,  for  purposes  of  comparison,  that  the  number  of  assess- 
ment, accident  and  health  association  certificates  in  force  in  lUinois  on  December 
31.  1917,  is  reported  as  228,030.  See  Superintendent  of  Insurance  Fred  W.  Potter's 
Summary  of  the  Standing,  December  SI,  1917,  of  the  Assessm,ent  Life,  Accident,  or 
Health  Associations  Transacting  Business  in  Illinois. 


40(5 

not  be  inaccurate  to  say,  after  making  allowances  for  the  looseness  with 
which  some  of  the  companies  have  obviously  interpreted  the  term  "wage- 
eamei*"'  in  making  their  returns,  that  about  100,000  of  the  Illinois  holders 
of  the  health  and  accident  policies  outstanding  against  the  companies  on 
December'31,  1917,  were  members  of  the  wage-earning  class. 

In  order  to  understand  the  full  significance  of  the  foregoing  state- 
ment in  its  relation  to  tlie  problem  of  health  insurance  it  is  necessary  to 
consider  the  composition  of  this  group  of  wage-earners  and  to  compare  it 
numerically  with  the  total  membership  of  the  wage-earning  class  in  Illi- 
nois. In  general  it  may  be  said  that  the  health  and  accident  insurance 
provided  by  the  casualty  companies  is  so  expensive  that  only  the  more 
highly  paid  wage-earners,  chiefly  mechanics  and  other  skilled  laborers  and 
employees  occupying  positions  of  responsibility,  feel  that  they  can  afford 
to  purchase  insurance  of  this  kind.  The  reasons  for  the  high  cost  of  thi^ 
insurance  will  be  discussed  later. 

(2)  Policij-Coiitract  used  by  Casualty  Companies. 

Three  kinds  of  policies  are  used  by  casualty  companies  in  selling 
health  and  accident  insurance:  health  policies,  accident  policies,  and 
combination  health  and  accident  policies.  Each  of  the  first  two  classes, 
as  the  names  indicate,  provides  only  the  kind  of  insurance  named;  the 
combination  health  and  accident  policies  insure  the  policyholder  in  one 
contract  against  both  accident  and  sickness.  Some  companies  write 
all  three  kinds  of  policies;  others  issue  only  the  combination  contracts. 

The  health  and  accident  policies  of  the  casualty  companies  are  also 
classified  as  "commercial"  and  "industrial.^^  Commercial  policies  com- 
monly provide  weekly  benefits  to  compensate  for  loss  of  time  from  dis- 
ability due  to  sickness  or  accident,  as  the  case  may  be,  ranging  from  $10 
to  $50  or  more  and  other  benefits  which  are  correspondingly  high,  and  are 
usually  sold  on  the  annual  premium  plan.^  Industrial  policies  provide 
smaller  benefits,  ranging  from  $20  to  $125  per  month  for  disability  re- 
sulting from  accident  or  disease,  and  are  usually  sold  on  the  monthly 
premium  plan  although  some  are  purchased  by  quarterly  and  many  by 
weekly  premium^.  The  commercial  policies  are  designed  to  meet  the 
needs  and  preferences  of  business  and  professional  men  and  the  better- 
paid  salaried  employees.  The  industrial  policies,  as  the  name  suggests. 
are  intended  to  attract  wage-earners. 

Health  and  accident  policies,  like  life  insurance  policies,  may  be 
written  on  individual  risks  or  a  group  of  persons  may  be  insured  under  a 
blanket  contract.  So  far  little  has  been  accomplished  in  the  attempts 
that  have  been  made  to  develop  the  use  of  gronp  health  and  accident  con- 
tracts in  the  United  States.  The  discussion  which  follows  in  the  present 
chapter  is  therefore  limited  to  the  business  in  individual  policies  and 
group  health  and  accident  insurance  is  left  for  consideration  in  the  re- 
port on  group  insurance.^^ 

» Some  policies  are  sold  to  farmers  in  Illinois  who  prefer  to  purchase  in  that 
way  on  the  three-year  basis  as  fire  insurance  is  often  sold. 
"See  Part  II,  Special  Report  IX. 


407 


11 


(3)   Benefits  Promised  in  Health  Insurance  Contracts. 

The  health  insurance  policies  formerly  sold  by  casualty  companies 
insured  against  disability  resulting  from  only  a  limited  number  of  dis- 
eases, which  were  enumerated  in  the  policy,  but  contracts  which  insuro 
against  nearly  all  diseases  are  now  sold  by  most  companies.  The  dis- 
eases most  commonly  excluded  are  diseases  "contracted"  *  *  * 
"while  the  insured  is  engaged  in  military  or  naval  service,"  diseases* 
caused  by  accidental  injuries,  disease  "contracted  and  suffered  without  the 
limits  of  the  United  States,  Canada  and  Europe,"  or  diseases  contracted 
within  the  tropics  or  within  certain  parts  of  them,  as  the  Philippine 
Islands  or  the  Panama  Canal  Zone,  and  diseases  contracted  in  Alaska 
and  "the  British  possessions  in  America  north  of  the  55th  degree  of  North 
Latitude,"  "sickness  resulting  from  the  use  of  intoxicants,  or  narcotics," 
"any  illness  not  common  to  both  sexes,"  any  "sickness  for  which  the 
insured  is  not  regularly  treated  by  a  legally  qualified  and  registered 
physician"  and  venereal  diseases.  Some  policies  contain  only  the  re- 
striction against  venereal  diseases;  few  if  any  of  the  policies  offered  for 
sale  in  Illinois  contain  all  of  the  restrictions  enumerated  above. 

Although  most  health  insurance  contracts  issued  in  Illinois  by 
casualty  companies  cover  many  and  frequently  nearly  all  diseases,  there  is 
some  sale  in  the  State  of  a  type  of  contract  which  covers  certain  specified 
diseases  only  and  is  therefore  cheaper  than  the  contracts  which  are  more 
inclusive  in  their  coverage.  Several  companies  offer  this  "limited  sick- 
ness contract"  to  the  public  in  Illinois  in  combination  with  an  accident 
insurance  contract  and  one  company  offers  the  contract  in  a  separate 
health  policy.  One  company  insures,  in  the  combination  policy  to  which 
reference  is  made,  against  disability  arising  "from  any  one  or  more  of  50 
diseases ;"^^  a  second  insures  against  disability  resulting  from  any  one 
or  more  of  42  diseases;  and  a  third  insures  against  disability  resulting 
from  any  one  or  more  of  29  diseases. 

The  health  insurance  policies  written  by  casualty  companies  provide 
for  a  number  of  benefits  to  cover  money  losses  which  occur  in  various 
wa3's  as  the  result  of  sickness.  The  most  important  of  these  benefits  is 
that  for  "loss  of  time."  It  is  the  object  of  this  to  indemnify  the  insured 
for  the  money  loss  which  he  suffers  through  disability  which  incapacitates 
him,  wholly  or  partially,  for  the  performance  of  the  duties  pertaining  to 
the  occupation  upon  which  he  depends  for  his  livelihood.  For  this  reason 
health  insurance  has  been  called  "income  insurance."  The  sum  paid  in 
a  given  case  is  not  determined,  however,   by  the  amount  of   income 

^^  The  discussion  in  this  section  applies  to  the  "siclcness  benefit"  or  "illness 
indemnity"  provisions  of  the  combined  health  and  accident  policies  as  well  as  to 
the  policies  which  provide  health  -insurance  only.  It  is  bashed  larg-e!y  upon  a 
study  of  sample  policies  submitted  to  the  Commission  by  the  casualty  companies 
doing  business  in  Illinois  in  response  to  a  request  for  a  complete  sample  set  of  all 
policies  being  offered  for  sale  within  the  State. 

^2  The  50  diseases  covered  are  as  follows :  "Acute  cerebral  meningitis,  Addi- 
son's disease,  aneurism  of  aorta,  angina  pectoris,  appendicitis,  Asiatic  cholera, 
Bright's  disease,  calculus  (renal),  cancer,  chicken  pox,  cirrhosis  of  liver,  colitis, 
systitis,  diabetes,  diphtheria,  dysentery,  endocarditis,  enteritis,  enterocolitis,  enteric 
catarrh,  epilepsy,  erysipelas,  felon,  gall  stones,  gastric  catarrh,  gastralgia,  gas- 
tritis, gastro-entertis,  hemorrhoids,  intussception,  malignant  pustule.  meaHles, 
mumps,  pericarditis,  peritonitis,  phlebitis,  pleurisy,  pneumonia,  Pott's  disease,  pye- 
litis, scarlatina,  scarlet  fever,  small-pox,  typhlitis,  typhoid  fever,  typhus  fever, 
varioloid,   vesicle  calculus,  volvulus,  or  yellow  fever." 


408 

actually  lost  by  the  insured  through  illness— the  "loss  of  time"  benefit 
may  be  paid  if  there  is  no  loss  of  income  whatever — but  is  fixed  by  the 
terms  of  the  policy  at  a  definite  amount  per  week  or  month  regardless  of 
the  effect  of  the  disability  suffered  upon  the  income  of  the  insured.  The 
only  relation  which  prevails  between  the  loss  of  time  benefit  provided  by  a 
given  policy  and  the  income  of  the  insured  is  that  the  indemnity  is 
ordinarily  fixed  at  a  figure  somewhat  less  than  that  of  the  income.  This 
is  insisted  upon  by  the  insurance  companies  in  order  to  avoid  the  moral 
hazard  always  present  in  over-insurance.^^ 

The  (commercial  policies  most  frequently  sold  in  Illinois  provide  for 
weeky  illness  indemnities  ranging  from  $25  to  $50  payable  for  a  period 
limited  to  fifty-two  consecutive  weeks,  for  "total  disability/'  or  "total  loss 
of  time/'  as  it  is  called  in  some  policies.  The  industrial  policies  most 
frequently  sold  provide  for  monthly  indemnities  of  $45  or  $50  for  "total 
disability."  Industrial  policies  providing  for  indemnities  as  low  as  $20 
per  month  are  not  uncommon,  however,  while  some  insuring  payments 
as  high  as  $100  or  $125  per  month  are  sold. 

"Total  disability"  is  usually  defined  in  the  health  insurance  policy 
as  disability  which  "shall  continuously  totally  disable  and  prevent  the 
Insured  from  transacting  every  kind  of  duty  pertaining  to  his  occupation 
and  shall  necessarily  and  continously  confine  him  in  the  house  where  he 
shall  be  regularly  visited  by  a  licensed  physician"  or  in  similar  language 
of  the  same  intent. 

In  addition  to  the  benefit  for  total  disability  just  described  most 
health  insurance  policies  provide  an  indemnity  for  disability  suffered  dur- 
ing the  period  of  convalescence  (or  a  limited  portion  of  it)  following  a 
totally  disabling  and  confining  sickness.  The  disability  suffered  during 
convalescence  may  be  total  or  partial.  Some  policies  provide  indemnity 
for  the  first  form  of  disability,  usually  called  "non-confining  total  disabil- 
ity" in  the  contract,  and  some  provide  indemnity  for  the  second  form 
which  is  commonly  called  "partial  disability." 

"JSTon-confining  total  disability"  is  defined  as  total  disability  which 
does  not  necessarily  confine  the  insured  to  the  house.  In  some  policies 
pa}Tnent  for  this  kind  of  disability  is  to  be  made  only  when  it  is  a  result 
of  the  confining  and  totally  disabling  disease  which  it  follows;  in  other 
policies  payment  is  also  to  be  made  for  "non-confining  total  disability" 
which  follows  a  confining  and  totally  disabling  sickness  but  is  the  result  of 
another  disease;  and  in  still  others  payment  is  to  be  made  for  "non-con- 
fining total  disability"  caused  by  any  disease  not  specifically  excluded, 
whether  it  follows  a  confining  and  totally  disabling  sickness  or  not. 

"Partial  disability"  is  variously  defined  in  different  policies  but 
practically  all  the  definitions  agree  in  making  inability  to  perform  a 
greater  or  smaller  portion  of  the  regular  duties  of  the  occupation  of  the 
insured  the  test  of  partial  disability.  To  illustrate,  one  company  de- 
fines partial  disability  in  one  of  its  health  insurance  contracts  as  disability 
"following  a  period  of  total  disability  *  *  *  (which)  shall  con- 
tinuously disable  and  prevent  the  Insured  from  performing  the  duties  of 
his  occupation  for  at  least  half  of  his  business  time  each  day;"  another 

"See  below,  p.  421. 


409 

compart}^  in  one  of  its  policies  defines  "partial  illness — disability"  as  dis- 
abilit}^  which  "continously  prevents  the  assured  *  *  *  from  per- 
forming any  important  duty  pertaining  to  his  occupation;"  and  a  third 
company  defines  partial  disability  as  disability,  not  total,  which  causes 
the  insui'ed  to  suffer  "a  material  loss  of  his  business  time."  Partial  dis- 
ability benefits  are  promised  in  some  policies  for  partial  disability  which 
does  not  follow  a  period  of  total  disability. 

The  amount  of  the  indemnity  paid  per  week  or  month  for  non-confin- 
ing total  disability  and  for  partial  disability  is  usually  one-half  of  the 
indmnity  paid  for  total  and  confining  disability,  although  in  some 
policies  and  under  certain  conditions  a  larger  proportion  is  paid.  The 
payment  of  the  indemnity  is  limited  in  most  commercial  policies  by  a 
provision  which  fixes  the  maximum  number  of  weeks  for  which  indemnity 
may  be  paid  on  account  of  sickness,  total  and  partial  disability  combined, 
or  total  confining  disability  and  total  non-confining  disability  combined, 
at  52  weeks.  That  is  to  say,  the  maximum  number  of  weeks  for  which 
the  indemnity  for  partial  disability  or  total  non-confining  disability  may 
be  paid  is  the  dift'erence  between  52  weeks  and  the  number  of  weeks  for 
which  the  indemnity  for  total,  confining  disability  has  been  paid.  In 
industrial  policies  the  period  covered  by  the  indemnities  mentioned 
varies  somewhat  more  than  in  the  case  of  commercial  policies  but  most 
industrial  policies  sold  in  Illinois  limit  the  total  maximum  length  of 
time  to  be  covered  by  the  total  and  partial  disability  indemnity  to- 
gether to  six  or  eight  months  and  provide  further  that  the  partial  dis- 
ability indemnity  or  the  non-confining  total  disability  indemnity,  as 
the  case  may  be,  shall  be  paid  for  not  to  exceed  one  or  two  months. 

An  attempt  has  been  made  in  the  foregoing  discussion  to  describe 
provisions  governing  the  payment  of  indemnities  for  loss  of  time  result- 
ing from  illness  disability  that  are  typical  of  the  health  insurance  poli- 
cies sold  by  casualty  insurance  companies  in  Illinois.  No  attempt  has 
been  made,  or  can  be  made  within  the  limits  prescribed  for  this  report, 
to  describe  all  of  the  various  loss  of  time  indemnities  offered  for  sale 
in  health  insurance  policies  in  the  State.  Some  attention  should  be 
given,  however,  to  certain  loss  of  time  benefits^  other  than  those  already 
mentioned,  which  are  more  or  less  frequently  found  in  the  health  insur- 
ance policies  now  being  sold. 

Some  policies  do  not  require  that  a  disability  suffered  by  the 
insured  confine  him  to  the  house  in  order  to  entitle  him  to  the  full 
weekly  or  monthly  payment  for  total  disability  but  provide  that  the 
full  indemnity  shall  be  paid  for  total  disability  resulting  from  non- 
confining illnesses.  A  few  commercial  policies  do  not  limit  the  pay- 
ment of  the  weekly  benefits  to  52  weeks  of  continuous  total  disability 
or  total  and  partial  disability  but  promise  the  payment  of  one-fourth 
of  the  full  weekly  benefit  "as  long  as  the  insured  continuously  suffers" 
total  disability  from  an  illness,  which  of  course  may  be  for  the  remainder 
of  his  life.  Some  policies  provide  specifically  that  the  full  loss  of  time 
indemnity  shall  be  paid  if  the  insured  is  totally  disabled  by  "carbun- 
cles, boils  or  felons"  or  "carbuncles,  boils,  felons,  abscesses  or  ulcers,'^ 
to  quote  the  longer  list  found  in  a  few  policies,  regardless  of  the  fact 


410 

that  his  disability  may  not  confine  the  insured  to  the  house.  Several 
policies  promise  to  pay  an  "indemnity  for  quarantine"  equal  to  the  full 
weekly  benefit  (double  it  in  one  policy)  for  a  period  not  to  exceed  ten 
weeks  in  case  the  insured  is  quarantined  by  order  of  the  "civil  authori- 
ties" because  of  an  "infectious  or  contagious  disease"  which  he  has 
contracted  and  "by  reason  of  said  quarantine  is  prevented  from  per- 
forming any  and  every  kind  of  duty  pertaining  to  his  occupation." 
Finally  many  of  the  policies  restrict  the  payment  of  the  usual  weekly 
or  monthly  indemnity  in  the  case  of  certain  chronic  diseases  and  dis- 
eases of  long  duration  by  providing  that  the  indemnity  shall  be  paid 
for  only  a  fraction  of  the  maximum  period.  Thus  one  industrial  policy 
which  promises  the  payment  of  a  monthly  illness  indemnity  for  a  maxi- 
mum of  six  months  for  most  diseases,  restricts  the  payment  of  the 
indemnity  to  "a  period  not  exceeding  one  month  in  any  one  policy 
year"  in  case  the  insured  suffers  total  and  confining  disability  "by  reason 
of  rheumatism,  tuberculosis,  paralysis,  neurasthenia,  sciatica,  Brighf  s 
disease,  apoplexy,  locomotor  ataxia,  cancer,  neuritis,  sprain  or  strains, 
lumbago,  orchitis,  hernia,  or  any  chronic  disease."  A  policy  issued  by 
another  company  carries  a  similar  restriction  but  adds  "lame  back," 
vaccination,  diabetes,  appendicitis,  varicose  veins,  dementia,  and  insanity 
to  the  list  of  diseases  excluded  from  liability  for  full  benefit.  A  third 
policy,  issued  by  a  third  company,  has  a  more  liberal  clause  governing 
"special  diseases"  in  which  the  maximum  period  for  which  the  weekly 
benefit  may  be  paid  is  reduced  from  twelve  months  to  six  months  and 
only  four  diseases — paralysis,  tuberculosis,  cancer  and  locomotor  ataxia — 
are  included.^* 

In  addition  to  the  benefits  paid  for  loss  of  time  which  have  Just 
been  described,  many  of  the  health  insurance  policies  sold  in  Illinois 
promise  one  or  more  of  a  number  of  other  benefits  to  cover  money 
losses  or  money  expenditures  caused  or  necessitated  by  sickness.  These 
include  payments  to  reimburse  the  insured,  within  specified  limits,  for 
hospital  expenses,  the  cost  of  surgical  operations  and  the  cost  of  medical 
attendance  or  of  the  services  of  a  trained  nurse,  and  payments  for 
blindness  and  paralysis  or  other  permanent  disability  and  for  funeral 
expenses.  Of  these  indemnities,  those  for  hospital  expenses  and  sur- 
gical operations  are  most  common;  in  fact  they  are  the  only  ones  of 
those  named  which  are  included  in  many  policies.^^ 

The  hospital  benefit  clause  provides  for  the  payment  of  a  weekly 
or  monthly  indemnity  in  addition  to  the  disability  benefit  in  case  the 
illness  of  the  insured  (usually  within  90  days  or  three  months  of  the 
beginning  of  the  illness  or  the  disability)  necessitates  his  confinement 
in  a  hospital.^*  In  some  policies  the  hospital  allowance  is  fixed  at  one- 
half  the  regular  weekly  or  monthly  benefit;  in  others,  it  is  made  equal 

"The  use  of  the  words  "more  liberal"  is  not  intended  to  disparage  the  sale  of 
policies  with  less  liberal  special  disease  clauses.  The  merits  of  any  particular 
insurance  policy  should  always  be  considered  in  relation  to  the  premium  paid  for 
the  policy. 

"Some  policies  do  not  contain  any  of  the  indemnities  enumerated  above. 

"Many  policies  containing  the  hospital  indemnity  clause  limit  the  payment  of 
the  indemnity  to  cases  where  the  insured  is  confined  in  a  "regularlv  incorporated" 
or  a  "licensed"  hospital. 


411 

to  the  regular  benefit;  frequently  it  is  made  to  cover  the  hospital 
charges  exactly  in  so  far  as  they  do  not  exceed  one-half  the  regular  sum. 
The  duration  of  the  period  for  which  the  hospital  allowance  will  be 
paid  is  limited,  in  diiferent  policies,  to  a  maximum  which  ranges  from 
10  to  26  weeks  for  the  commercial  policies  and  which  is  commonly 
three  months  for  the  industrial  policies.  In  policies  which  also  pro- 
vide for  the  payment  of  specific  sums  for  surgical  operations  it  is  often 
stipulated  that  no  hospital  allowance  shall  be  paid  if  the  insured  claims 
the  benefit  of  the  surgical  operations  clause. 

The  surgical  operations  clause  usually  promises  the  payment  of 
a  fixed  amount  of  money,  which  varies  according  to  the  nature  of  the 
operation  and  the  amount  of  the  weekly  or  monthly  disability  benefit, 
in  case  the  insured  has  io  undergo  any  one  of  a  number  of  specified 
surgical  operations,  as  the  result  of  the  illness  which  has  disabled  him, 
within  a  specified  time  (usually  90  days  in  commercial  policies)  after 
the  commencement  of  the  illness.  Sometimes,  however,  the  surgical 
operations  clause  provides  for  the  payment  of  the  full  cost  of  the  oper- 
ation, regardless  of  its  nature,  in  so  far  as  the  cost  does  not  exceed  a 
certain  multiple,  e.  g.  double,  the  regular  disability  indemnity.  The 
policies  which  promise  the  payment  of  surgical  indemnities  of  fixed 
amounts  according  to  the  nature  of  the  operation  commonly  enumerate 
from  30  to  40  operations.^^  Three  policies  stipulate  that  the  insured 
shall  not  receive  indemnity  for  more  than  one  operation  for  any  one 
sickness  or  disease;  if  he  has  to  undergo  more  than  one  operation  he 

"  The  following'  schedule  is  fairly  typical,  as  respects  both  operations  included 
and  amounts  payable,  of  the  health  insurance  policies  which  promise  surgical 
operation  indemnities. 

Schedule  of  Operations  to  the  Insured.  Amounts  payable  in  addition  to  other 
benefits  for  each  Five  Dollars  of  weekly  indemnity. 

Appendicitis    ( see    Laparotomy) 

Aneurism    (Tumor  of  Artery — Ligation $10.00 

Abscess    or    Boil — Incision 1.00 

Bone    Abscess — Trephining-    5.00 

Bronchotomy,   Thyrotomy,   Laryngotomy,    Laryngotracheotomy,    or   Trache- 
otomy       10,00 

Carbuncle — Incision   and  Treatment 1-00 

Eye.  Ear.  Nose  And  Throat — Any  cutting  operations 2.00 

Felon — Incision 1-00 

Ganglion   (Cystic  Tumor  of  Tendon  Sheath) — Incision  and  Curetting 3.00 

Hernia    (Abdominal) — Any    ovitting    operation    for    the    radical    cure    of    the 

Reducible.    Irreducible    or    Strangulated   form 20.00 

Hydrocele — Tapping — Incision  or  Excision  of  Sac 5.00 

Ingrowing    Toe    Nail — Removal .  •  2.00 

Intestinal    Obstruction    (see    Laparotomy) 

Kidney — Fixation    or    removal 20.00 

Laparotomy    (opening   of   the   abdominal    cavity   for   an   operation   on   any 

organ  contained  therein,   or  for  Exploratory  Incision) 20.00 

Lithotomy   (operation  for  removal  of  stone  in  bladder) — any  cutting 20.00 

Mastoiditis — Operation    for    10.00 

Oesophogotomy  for   Structure  or  other  cause 20.00 

Parentecis — Tapping   of    Abdomen    5.00 

Bladder     5.00 

Ear    Drum     on  nn 

Peritonitis    (see    Laparotomy) 20.00 

Rectum — Operation  for — 

Hemorrhoids    (external   or  internal) — Excision  or  Ligation 5.00 

Prolapsed — Operation    for     5.00 

Fistula    in    Ano — Incison 5.00 

Polypus — Extirpation      onnn 

Malignant    Stricture — Excision    or   Colostomy 20.00 

Tumors — Extirpation  from  any  part  of  the  body — 

Benign     3.00 

Malignant     ^nn 

Varicose  Veins — Ligation  or  Excision 5.00 

Varicocele — Acupressure — Ligation    or   Excision 5.U0 


412   . 

is  usually  either  paid  for  that  operation  for  which  the  allowance  is 
largest  or,  which  amounts  to  the  same  thing,  he  is  given  the  privilege 
of  choosing  the  operation  for  which  he  is  to  be  indemnified. 

The  "medical  attendance"  or  "medical  treatment"  clause  is  found 
more  commonly  in  accident  insurance  contracts  than  in  the  health 
policies. but  some  of. the  latter  contain  the  clause/^  The  clause  as  used 
in  commercial  health  policies  usually  provides  for  the  reimbursement 
of  the  insured  for  expenditures  for  the  services  of  a  physician  to  an 
amount  not  exceeding  the  weekly  benefit  promised  in  the  policy,  in  case 
the  insured  suffers  an  illness  which  requires  medical  treatment  or 
medical  attendance  but  does  not  result  in  disability. 

A  few  policies  provide  for  the  payment  of  a  limited  amount  to 
cover  nurses'  fees  in  lieu  of  the  hospital  allowance  in  cases  where  the 
insured,  while  suffering  disability  from  illness,  is  attended  by  a  grad- 
uate nurse  although  not  confined  in  a  hospital.  The  amount  of  the 
indemnity  is  usually  subject  to  the  same  limitations  as  the  amount  of 
the  hospital  indemnity. 

^ext  to  the  allowances  for  hospital  expenses  and  surgical  opera- 
tions the  "blindness  and  paralysis"  benefit  or  the  "permanent  disability" 
indemnity,  as  it  is  called  in  some  policies  which  do  not  limit  the  forms 
of  disability  for  which  the  indemnity  is  to  be  paid  to  blindness  and 
paralysis,  is  the  most  conmion  of  the  minor  benefits  promised  in  the 
health  insurance  policies  sold  by  casualty  companies.  This  benefit  is 
a  payment  for  permanent,  total  disability.  Its  nature  can  perhaps  best 
be  made  clear  by  quoting  a  typical  section  which  provides  for  it  from 
a  policy  sold  in  Illinois  by  a  well-known  casualty  company.  This  sec- 
tion reads  in  part  as  follows: 

''Special  indemnity  for  blindness  or  paralysis. — In  the  event  that 
any  disease  for  which  indemnity  is  payable  under  the  terms  of  this 
policy  shall  result,  independently  of  other  causes,  in  the  irrecoverable 
loss  of  the  entire  sight  of  both  eyes  or  in  permanent  paralysis  whereby 
the  insured  shall  lose  the  use  of  both  hands  or  both  feet,  or  of  one  hand 
and  one  foot,  and  on  account  of  either  of  said  conditions  be  permanently 
unable  to  engage  in  any  labor  or  occupation,  the  company  will  pay  said 
weekly  sickness  indemnity  for  the  period  of  such  blindness  or  paralysis, 
but  not  extending  beyond  one  hundred  and  four  weeks  from  the  com- 
mencement of  the  illness  or  disease  causing  the  blindness  or  paralysis. 

"No  payment  under  the  terms  of  this  part  *  *  *  shall  be  due 
or  payable  until  such  permanent  blindness  or  paralysis  has  continued  for 
one  year ;  further  payments,  if  any,  shall  then  be  due  and  payable  every 
sixty  days  but  no  payment  whatever  shall  be  due  or  payable  except  upon 
proof  of  the  continuance  of  the  blindness  or  paralysis  during  the  period 
for  which  payment  is  claimed." 

The  above  section  further  provides  that  the  special  indemnity  for 
blindness  or  paralysis  and  the  regular  weekly  benefit  for  sickness  shall 
not  be  paid  "for  any  concurrent  time,"  that  is,  that  the  payment  of  the 
regular  weekly  benefit  for  sickness  shall  cease  when  the  payment  of  the 
special  indemnity  begins. 

"  In  accident  policies  the  clause  often  reads  "Surgeon's  Fees"  instead  of  "Medi- 
cal Attendance." 


413 

The  policies  which  cover  permanent  and  total  disability  from  other 
causes  as  well  as  from  blindness  and  paralysis  vary  somewhat  in  their 
terms.  Most  of  these  policies,  however,  cover  permanent  and  total  dis- 
ability arising  from  the  permanent  and  entire  loss  of  the  *'use  of  both 
hands  or  both  feet,  or  one  hand  and  one  foof '  as  the  result  of  sickness 
in  addition  to  permanent  and  total  disability  arising  from  "insurable 
paralysis."^^  A  few  of  the  industrial  policies  which  have  been  submitted 
to  the  Commission  cover  permanent  total  disability  arising  from  any 
cause  for  which  the  ordinary  (temporary)  total  disability  benefit  is  pay- 
able in  a  clause  which  provides  for  the  payment  of  a  fraction  (for  ex- 
ample, one-fourth)  of  the  regular  monthly  sum  for  as  long  a  time  as 
the  total  disability  continues. 

In  policies  which  provide  for  health  insurance  only,  the  amount  to 
be  paid  under  the  "blindness  and  paralysis'^  or  the  "permanent  dis- 
ability''' section  is  usually  stated  in  terms  of  the  maximum  number  of 
weeks  or  months  for  which  the  regular  sickness  benefit  will  be  paid  from 
the  commencement  of  the  illness  including  the  period  for  which  the 
regular  indemnity  is  ordinarily  payable,  as  in  the  policy  quoted  above. 
The  maxium  is  fixed  at  104  weeks  in  most  commercial  policies,  but  it  is 
frequently  fixed  at  100  weeks  and  sometimes  at  150  weeks,  156  weeks 
(three  years)  or  200  weeks. 

In  combination  health  and  accident  policies  the  sum  paid  for  perma- 
nent disability  resulting  from  sickness  is  sometimes  stated  in  the  same 
terms  as  in  the  health  policies  and  sometimes  as  a  fraction  of  the 
"principal  sum,"  which  is  the  amount  payable  under  the  terms  of  an 
accident  policy  for  death  resulting  from  accidental  bodily  injuries.^^ 
When  stated  m  the  latter  way  the  amount  is  usually  fixed  at  one-fourth, 
one-third  or  one-half  of  the  principal  sum  and  made  payable  in  full  at 
the  end  of  the  first  year  of  total,  permanent  disability. 

Only  five  of  the  44  casualty  companies  which  returned  the  question- 
naires sent  them  on  behalf  of  the  Commission  reported  that  they  provide 
funeral  benefits  in  case  of  death  by  sickness  in  policies  sold  in  Illinois. 
Two  of  these  companies  are  Illinois  stock  companies  which  are  authorized 
by  their  charters  to  engage  in  the  life  insurance  business  and  which  write 
a  funeral  benefit  clause  in  some  of  their  health  contracts  in  return  for 
the  payment  of  a  life  insurance  premium  to  cover  the  cost.  Another 
company  is  a  mutual  casualty  company  organized  under  the  laws  of  this 
State;  and  the  laws  of  Illinois  permit  mutual  casualty  companies  to  in- 
clude provision  for  funeral  benefits  in  their  health  insurance  policies.^^ 
The  remaining  two  companies  are  stock  companies  organized  under  the 
laws  of  other  states.  Both  are  life  insurance  companies  with  charter 
powers  to  do  health  and  accident  business.  The  amount  paid  as  funeral 
benefit  is  $100  in  the  case  of  each  of  the  five  companies  mentioned  ex- 
cept that  two  of  the  companies  provide  for  the  payment  of  smaller  sums 
if  death  occurs  within  one  year  of  the  date  of  the  policy. 

^'  A  few  policies  include  disability  caused  by  insanity,  if  insanity  results  from 
a  disease  for  which  the  insured  is  entitled  to  receive  indemnity,  in  the  permanent 
disability  clause. 

^^  See  p.  414  below. 

^  See  Insurance  Laws  of  the  State  of  Illinois^  1917,  pp.  137  and  138. 


414 

(4)  Benefits  Promised  in  Accident  Insurance  Contracts. 

The  accident  insurance  policies  sold  by  casualty  companies  resem- 
ble in  many  respects  the  health  insurance  contracts  which  have  just  been 
described.  It  will  therefore  be  necessary  in  this  section  only  to  indicate 
the  similarities  and  to  describe  briefly  the  points  of  contrast. 

It  is  the  purpose  of  accident  insurance  to  protect  the  insured,  to 
quote  a  typical  insuring  clause,  "against  loss  resulting  directly  and  in- 
dependently of  all  other  causes,  from  bodily  injuries  effected  solely 
through  external,  violent  and  accidental  means,  suicide  (sane  or  insane) 
not  included.^^  The  principal  losses  covered  are  loss  of  time,  loss  of 
sight,  loss  of  limb  and  death. 

One  of  the  most  important  respects  in  which  the  typical  accident 
insurance  policy  differs  from  the  typical  health  insurance  policy  is  in 
the  provision  in  the  former  for  the  payment  of  a  sum  called  the  "princi- 
pal sum"  in  the  "event  of  the  death  of  the  insured  from  accidental  means. ^^ 
It  will  be  recalled  that  only  five  companies  writing  health  insurance  re- 
ported to  the  Commission  that  they  included  provision  for  funeral  bene- 
fits in  health  policies  issued  by  them  and  that  the  maximum  amount 
paid  was,  in  each  case,  $100. 

The  amount  stipulated  as  the  principal  sum  varies  with  the  nature 
of  the  policy  and,  for  a  given  class  of  risks,  with  the  amount  of  the 
premium  paid  for  it.  Commercial  accident  policies  commonly  carry 
$5,000  or  $7,500  as  the  principal  sum  for  every  $25  of  weekly  indemnity 
for  disability  resulting  from  accidental  injury.  Industrial  policies 
differ  widely  in  respect  to  the  amount  of  the  principal  sum;  one  com- 
pany, for  example,  writes  industrial  policies  which  provide  for  the  pay- 
ment in  the  event  of  accidental  death  of  sums  ranging  from  $100  to 
$1,200  according  to  the  class  of  risk  and  the  premium  paid  for  the 
policy. 

The  sums  paid  for  loss  of  sight  and  loss  of  limb  in  the  typical 
accident  policy  are  fixed  in  terms  of  the  principal  sum.  The  schedule 
usually  runs  as  follows : 

For  loss  of.*  Indemnity. 

Both  hands   The  principal  sum 

Both  feet   The  principal  sum 

One  hand  and  one  foot The  principal  sum 

Entire  sight  of  both  eyes The  principal  sum 

Either  hand  or  either  foot One-half  the  principal  sum 

Either   eye fOne-third  the  principal  sum 

•  "Loss"  Is  defined  in  a  typical  policy  as  meaning  "with  regard  to  hands  and 
feet,  dismemberment  by  severance  at  or  above  wrist  or  ankle  joints  ;  with  regard  to 
eyes,  entire  and  irrecoverable  loss  of  sight"     *      *     *. 

t  One-half  in  some  policies. 

Some  policies  also  provide  specific  indemnities  in  terms  of  the  prin- 
cipal sum  for  the  loss  of  either  arm  or  either  leg,  the  loss  of  either  hand 
or  foot  and  the  sight  of  one  eye,  and  the  loss  of  the  thumb  and  index 
finger  of  either  hand.  The  indemnities  for  these  losses  have  not  been  as 
well  standardized  as  the  indemnities  for  the  losses  indicated  in  the  above 
table;  in  general  they  vary  from  two-thirds  or  three-fourths  of  the 
principal  sum  payable,  in  some  policies,  for  the  loss  of  an  arm  or  leg^® 

^  Some  accident  policies  do  not  provide  for  the  payment  of  a  principal  sum. 
^  "Loss"  with  regard  to  arms  and  legs  means  severance  at  or  above  the  elbow 
or  knee. 


415 

to  one-fifth  or  one-sixth  which  some  policies  promise  for  the  loss  of  the 
thumb  and  index  finger  of  either  hand.-^ 

Most  policies  provide  that  the  dismemberment  and  loss  of  sight  in- 
demnities shall  be  paid  only  if  the  losses  occur  within  ninety  days  of  the 
date  of  the  accident  or,  if  the  injuries  continuously  disable  the  insured 
from  the  accident  to  the  date  of  the  loss,  within  200  weeks.  The  reason 
for  this  time  limitation  has  been  stated  as  follows  by  a  representative  of 
the  casualty  companies.^^ 

^'Experience  has  shown  that  if  the  loss  is  remote  in  period  of  time 
from  the  accident  it  will  probably  be  contributed  to  by  disease,  or  by 
causes  other  than  accidental  and,  therefore,  not  contemplated  being 
covered  by  the  policy,  and  it  is  to  afford  the  company  protection  against 
liability  for  such  complicated  cases  that  the  time  within  which  the  loss 
must  be  incurred  is  thus  limited  and  qualified.'^ 

In  addition  to  the  specific  indemnities  for  death,  dismemberment 
and  loss  of  sight,  accident  policies  provide  for  the  payment  of  the  weekly 
or  monthly  benefit  for  total  disability  which  continues  from  the  date  of 
the  accident  to  the  date  of  the  occurrence  of  one  of  the  losses  mentioned.-^ 

The  weekly  or  monthly  indemnity  for  total  disability  in  accident 
policies  is  similar  in  amount  (and  also  in  respect  to  the  conditions  under 
which  it  becomes  payable)  to  the  weekly  or  monthly  payment  for  total 
disability  in  health  policies.  The  former  differs  from  the  latter,  how- 
ever, in  the  time  limit  placed  upon  its  payment,  which  ranges  from  two 
years  in  some  policies  to  "so  long  as  the  insured  lives  and  suffers  such 
total  disability^  in  others,  instead  of  being  fixed  at  six  or  eight  months 
as  in  most  industrial  health  policies  or  52  weeks  as  in  most  commercial 
health  policies. 

Partial  disability  is  defined  in  about  the  same  terms  in  accident 
policies  as  in  health  policies.  Payment  of  the  indemnity  for  partial 
disability  from  accident  is  usually  limited  to  one-half  of  the  amount 
paid  for  total  disability  and  to  26  or  52  weeks  time. 

The  weekly  and  monthly  payments  for  total  disability  described 
above  are  paid  for  injuries  which  do  not  result  in  any  of  the  specific 
losses  indicated  in  the  table  and  discussion  on  page  416.  The  insured 
is  usually  given  the  option,  however,  of  claiming  the  payment  of  certain 
fixed  sums,  called  "elective"  or  "optional  indemnities,"  in  lieu  of  the 
weekly  or  monthly  indemnities  in  case  he  suffers  certain*  injuries  which 
are  specified  in  the  policy  and  which  include  loss  of  fingers  or  toes,  dis- 
locations and  fractures.  This  option  gives  the  insured  the  opportunity 
to  secure  an  immediate  settlement  of  his  claim  in  full  without  waiting 
for  the  payment  of  the  regular  weekly  or  monthly  indemnities — an 

^  "Loss"  as  here  used  means  "severance  at  or  above  the  metacarpo-phalangeal 
joint." 

^  F.  Leroy  Templeton  in  chapter  on  "The  Policy"  in  Dunham's  Biosiness  of  In- 
surance, Vol.  II,  p.  24. 

2^  Accident  policies  usually  provide  that  only  one  of  the  specific  indemnities 
mentioned  shall  be  paid  for  injuries  from  a  given  accident  and  that  the  policy  shall 
terminate  with  the  payment  of  this  indemnity. 


416 

opportunity   which   may   prove   desirable   to   an   injured   person   hard 
pressed  for  cash.^^ 

The  hospital,  surgical  operation  and  medical  treatment  indem- 
nities in  accident  policies  are  similar  to  those  in  health  policies.  The 
surgical  operations  schedule  in  the  accident  policy  necessarily  differs 
from  that  in  the  health  policy  because  of  the  inclusion  in  the  former 
of  operations  to  reduce  fractures  and  dislocations,  amputations  and  the 
treatment  of  gun-shot  wounds  and  the  like,  but  where  the  same  operation 
occurs  in  both  schedules  the  amount  allowed  is  usually  the  same  for  the 
same  weekly  or  monthly  indemnity.^^  Accident  policies  which  contain 
the  surgical  operation  indemnity  feature  commonly  stipulate  that  any 
operation  for  which  an  allowance  is  paid  must  be  performed  within 
ninety  days  of  the  date  of  the  accident,  just  as  health  policies  make  a 

"The  following-  schedule  is  typical  of  the  elective  indemnities  provided  in  com- 
mercial accident  policies : 

Schedule  of  elective  indemnities.     The  amounts  specified  in  the  following-  "Sched- 
ule of  Indemnities"  are  payable  i  fthe  policy  is  issued  for  a  single  weekly  indemnity 
of  twenty-five  dollars   ($25)  ;  proportionate  amounts  being  payable  if  the  policy  is 
issued  for  a  larger  or  smaller  amount. 
For  Loss  of  Certain  Members  by  Removal : 

Within  ninety  days  after  injury,  viz. :     Of  one  or  more  fingers  (at  least 

one  entire  phalanx) $150.00 

Of  one  or  more  entire  toes 200.00 

For  Complete  Hernia,  caused  solely  and  directly  by  accidental  injury 70.00 

For  Complete  Dislocation,  viz. : 

Of  the  shoulder    100.00 

Of  the  elbow     100.00 

Of  the  wrist    125.00 

Of  the  hip 300.00 

Of  the  knee     150.00 

Of  any  bones  of  foot 150.00 

Of  the  ankle 150.00 

Of  two  or  more  toes 50.00 

Of  two  or  more  fingers 50.00 

For  the  Complete  Fracture  of  Bones,  viz. : 

Of  the  skull,  both  tables 325.00 

Of  the  lower  jaw 75.00 

Of  the  collar  bone    150  00 

Of  the  pelvis    250.00 

Of  the  thigh   300.00 

Of  the  leg    200.00 

Of  the  knee  cap 200.00 

Of  the  arm  between  elbow  and  shoulder 30o!oO 

Of  the  forearm  between  the  wrist  and  elbow 150.00 

Of  two  or  more  ribs 100.00 

Of  the  foot    125.00 

Of  the  hand    125,00 

Of  two  or  more  toes .*...!.!*.!.*!....,..         100.00 

Of  two  or  more  fingers !.*.!!'.!!.       10o!oO 

28  Tj^g  following  schedule  is  fairly  typical,  as  respects'  bo'tti*  operations  included 
and  amounts  payable,  of  th'e  accident  insurance  policies  which  promise  surgical 
operation  mdemnities.  The  amounts  specified  are  payable  if  the  policy  is  issued 
for  a  weekly  indemnity  of  $25  ;  amounts  proportionately  higher  or  lower  are  payable 
if  the  policy  is  issued  for  a  larger  or  smaller  amount.  Schedule  of  Operations. 
Amputation  of : 

Foot,  hand  or  forearm ■. $   25  00 

Leg,  at  or  below  knee 50  00 

Arm,  above  elbow '. 50  00 

™sh :::::::::::  :■.::*.::::: :    100:00 

Fingers,  one  or  more  entire 10  00 

Toes,  one  or  more  entire 25  00 

Reduction  of  Dislocation  of :  

Shoulder,  elbow,  hip,  knee  or  ankle 25  00 

Wrist  or  jaw 1500 

Fingers,  ojie  or  more *    ! i  n  no 

Excision  of:                                                         ■^"•"" 

Shoulder,  hip,  or  knee-joint 100  00 

Elbow,  wrist,  or  ankle-joint 50  00 

Laparotomy:    (Opening  of  the  abdominal  cavity  for  ari  operation' on  any 

organ  contained  therein) ^qq  qo 

Incision  for:  Synovitis  (inflammation  of  the  lining  membrane  of  a  jointV.*.*  25^00 

Injection  of:  Anti-tetanic  serum  into  frontal  lobe  of  brain.    .  100  00 

Sequestrotomy :    (Removal  of  dead  bone) 3500 


417 

similar  stipulation  with,  respect  to  the  date  of  the  commencement  of  the 
disabling  sickness.  The  medical  or  surgical  treatment  indemnity  of  the 
accident  insurance  policy  is  the  counterpart  of  the  medical  attendance 
or  medical  treatment  indemnity  of  the  health  insurance  policy,  usually 
covering  the  cost  of  the  treatment  provided  it  does  not  exceed  the  amount 
of  one  week's  benefit. 

Like  some  health  policies  a  few  accident  policies  have  clauses  which 
make  specific  provision  for  total  disability  resulting  from  paralysis. 
In  these  policies  it  is  provided  that  if  paralysis  of  a  character  to  produce 
total  disability  occurs  within  ninety  days  of  the  date  of  accident  or  dur- 
ing a  period  of  continuous  total  disability  caused  by  accidental  injuries 
a  specified  sum  shall  be  paid  in  addition  to  the  accrued  weekly  benefit 
and  in  lieu  of  all  other  indemnity.  The  amount  of  the  paralysis  in- 
demnity varies  in  different  policies  from  one-third  or  one-half  to  100 
per  cent  of  the  principal  sum.  A  number  of  policies  pay  the  same 
amount  for  loss  of  speech  or  hearing  and  a  number  pay  it  for  insanity 
resulting  from  accidental  injuries.  The  "loss  of  sight"  indemnity, 
which  corresponds  to  the  "blindness'^  indemnity  in  health  policies,  has 
already  been  described. 

Accident  insurance  was  originally  designed  to  cover  the  hazards  of 
travel  by  railroad  and  steamboat.  This  original  purpose  is  still  shown 
in  many  policies  by  provisions  which  call  for  the  payment  of  double 
indemnities  for  loss  of  life,  limb,  sight  or  time  through  accidents  of 
travel. 

(5)   Other  Features  of  Health  and  Accident  Policies. 

In  order  to  encourage  the  insured  to  renew  his  policy  from  year  to 
year,  or  month  to  month  or,  in  the  case  of  policies  on  which  premiums 
are  payable  monthly,  to  pay  his  premiums  annually  or  semi-annually 
in  advance,  many  accident  contracts  and  a  few  health  contracts  contain 
an  "accumulations"  or  "annual  increase"  clause.  In  commercial  acci- 
dent policies  the  clause  commonly  provides  that  the  principal  sum,  and 
consequently  the  sum  payable  for  death,  loss  of  limb  or  loss  of  sight, 
shall  be  increased  10  per  cent  of  its  original  amount  each  year  if  suc- 
cessive premiums  are  paid  annually  in  advance  until  the  principal  sum 

Reduction  of  Fracture  of : 

Nose,  lower  jaw,  collar  bone  or  shoulder  blade $  25.00 

Breast  bone 10.00 

Rib  or  ribs 10.00 

Upper  arm 35.00 

Forearm,  one  or  both  bones 25,00 

Wrist  or  hand 15.00 

Fingers,   one   or  more 10.00 

Pelvis  or  Sacrum,  any  of  th'e  bones  of 50.00 

Coccyx    10.00 

Thig-h    75.00 

Knee  cap   50.00 

Leg  bones,  one  or  both 50.00 

Foot,  two  or  more  bones  not  toes 15.00 

Toes,  one  or  more 10.00 

Gunshot  Wounds  :  Removal  of  shot  or  bullet 25.00 

Skull  Trephining :  For  fracture 100.00 

Suturing  wounds    5.00 

In  addition  to  the  operations  enumerated  above  some  policies  include  one  or  more 

of  the  following :  abscess,  incision  of ;  aneurism,  tying  of  artery  ;  eye,  ear,  nose  or 

throat,  any  cutting  operation;  hernia  (abdominal),  any  cutting  operation  for  the 
radical  cure  of  the  reducible,  irreducible  or  strangulated  form ;  and  hydrophobia, 
Pasteur  treatment. 

—27  H  I 


418 

has  been  increased  by  50  per  cent  after  which  tliere  shall  be  no  further 
increases.  If  premiums  are  paid  semi-annually  or^  in  some  policies, 
quarterly  the  clause  provides  that  the  rate  of  increase  shall  be  5  instead 
of  10  per  cent  with. the  same  maximum  aggregate  accumulation  of  50 
per  cent.  In  some  of  the  industrial  policies  which  contain  an  accumu- 
lations clause  the  clause  provides  that  the  principal  sum  shall  be  in- 
creased 5  per  cent,  up  to  a  maximum  aggregate  of  50  per  cent,  ^*for 
each  full  three  months  (for  each  month  in  some  policies)  immediately 
preceding  the  date  of  the  accident  that  this  policy  shall  have  been 
maintained  in  continuous  force."  In  other  industrial  accident  policies 
and  in  some  commercial  accident  policies  the  accumulation  feature  is 
applied  to  the  monthly  or  weekly  benefit  for  disability;  sometimes  it 
is  also  applied  to  the  indemnities  specified  in  the  schedule  of  minor 
injuries  and  the  schedule  of  surgical  operations.  In  industrial  accident 
policies  in  which  the  accumulation  feature  is  applied  to  the  monthlj^ 
indemnity  the  payment  of  the  increased  sum  is  usually  a  reward  for 
the  payment  of  premiums  annually  or  semi-annually  in  advance.  When 
the  accumulations  clause  is  included  in  a  health  policy  it  is  applied  to 
the  weekly  or  monthly  disability  indemnity,  rarely  to  other  indemnities. 

The  "identification  indemnity"  clause  is  a  feature  of  many  health 
and  accident  policies.  The  clause  commonly  provides,  to  quote  the 
language  of  a  typical  combination  health  and  accident  policy,  that 
"if  the  insured,  by  reason  of  injury  or  illness,  shall  be  physically  unable 
to  communicate  with  friends,  the  company  upon  receipt  of  a.  telegram 
or  other  message  giving  the  number  of  the  policy,  will  immediately 
transmit  to  his  relatives  or  friends  any  information  respecting  him 
and  will  defray  the  expense  necessary  to  put  the  insured  in  the  care 
of  friends,  within  the  sum  of  one  hundred  dollars."^^ 

The  terms  "weekly"  and  "monthly"  as  used  in  describing  benefits 
for  disability  resulting  from  accidental  injuries  or  illness  have  refer- 
ence merely  to  the  rate  of  indemnity  and  do  not  indicate  the  time  at 
which,  or  the  frequency  with  which  the  payment  in  question  is  to  be 
made  to  the  insured.  The  time  or  frequency  of  payment  of  the  dis- 
ability indemnity  may  be  a  matter  of  great  importance  to  the  insured. 
For  that  reason  the  law  of  Illinois  requires  that  upon  request  of  the 
insured  payment  shall  be  made  at  least  once  in  every  60  days  of  half 
or  more  of  the  indemnity  which  has  accrued  since  the  last  payment  and 
that  any  balance  remaining  unpaid  at  the  termination  of  the  period  for 
which  the  insurance  company  is  liable  shall  be  paid  "immediately  upon 
receipt  of  due  proof."^^  In  accordance  with  the  law  most  policies  sold 
in  Illinois  provide  for  the  payment  of  instalments  of  the  disability 
benefit  every  30  or  60  days  or  the  nearest  equivalent  in  weeks  or  months. 

The  duration  of  the  insurance  contract  is  usually  limited  to  one  year 
in  the  case  of  commercial  health  and  accident  policies,^ ^  and  to  one 
month  in  the  case  of  industrial  policies.  The  insurance  company,  how- 
ever, usually  reserves  the  right  to  cancel  the  policy  at  any  time  upon 

29Sorne  policies  limit  the  "identification  indemnity"  to  four  times  the  weekly 
indemnity  ;  a  number  of  industrial  polices  fix  it  at  not  to  exceed  twenty-five  dollars. 

^Insurance  Laws  of  the  State  of  Illinois,  1917,  p.  129 

"Accident  policies  are  frequently  written  for  shorter  periods,  especially  policies 
which  cover  the  hazards  of  railway  travel.  j-  i^    xu  co 


419 

repayment  to  the  insured  of  the  unearned  premium  and  it  permits  the 
insured  to  renew  his  polic}'  upon  its  expiration,  unless  the  company- 
desires  to  discontinue  the  risk,  by  simply  paying"  the  premium  for  a 
new  term.  The  purpose  of  the  cancellation  privilege  is  to  p^rotect  the 
company  against  an  adverse  change  in  the  risk  upon  which  it  had  not 
counted  in  fixing  its  rates. 

In  deciding  as  to  the  eligibility  of  an  applicant  for  health  or  acci- 
dent insurance  casualty  companies  consider  his  sex,  age,  color  or  race, 
phj^sical  characteristics  and  condition,  occupation,  place  of  residence, 
other  health  or  accident  insurance  carried  by  him  and  the  relation 
between  his  income  and  the  total  amount  of  weekly  or  monthly  in- 
demnity which  he  could  claim  under  all  policies  which  he  carries  in 
case  he  were  disabled  by  illness  or  accidental  injuries. 

Some  companies  accept  "male  risks"  only;  others  accept  "female 
risks"  under  certain  contracts  drawn  exclusively  for  women;  while 
still  others  insure  men  and  women  on  the  same  terms.  The  companies 
which  do  not  insure  women  and  those  which  restrict  women  to  special 
policies  claim  that  there  are  substantial  grounds  for  discriminating 
against  women,  asserting  that  the  recorded  experience  with  female 
risks  is  too  inadequate  to  serve  as  the  basis  for  scientific  rates,  that  it 
is  more  difficult  to  detect  malingering  and  simulation  in  the  case  of 
women  than  in  that  of  men,  that  women  are  more  frequently  disabled 
than  men  or  that  there  is  a  great  moral  hazard  in  the  insurance  of 
women  against  loss  of  time  because  disability  in  the  case  of  women 
frequently  does  not  influence  the  amount  of  income  received  by  them 
and  hence  may  be  used  as  the  basis  for  what  is  really  an  unjust  claim 
f  or»  indemnity. 

The  age  limits  within  which  applicants  for  health  and  accident 
insurance  are  accepted  as  policyholders  vary  for  the  two  kinds  of  insur- 
ance and  between  different  companies  for  the  same  kind  of  insurance. 
Most  companies  do  not  accept  applicants  for  health  insurance  who  are 
less  than  18  years  of  age  nor  more  than  60  or  65  years  of  age  at  the 
nearest  birthday;  a  few,  however,  accept  applicants  as  young  as  16  or 
17.  The  lower  age  limit  for  accident  insurance  is  also  usually  18  but 
the  upper  limit  is  frequently  as  high  as  70  years. 

Several  casualty  companies  have  reported  to  the  Commission  that 
they  consider  persons  of  certain  races  as  undesirable  risks  but  the 
Commission  is  unable  to  state  the  extent  to  which  casualty  companies 
generally  discriminate  against  wage-earners  in  Illinois  on  account  of 
race  in  soliciting  "prospects."  The  races  mentioned  by  one  or  more 
of  the  companies  reporting  on  this  matter  as  undesirable  from  an  insur- 
ance standpoint  include  the  Hebrew,  Hungarian  and  Negro  jaces, 
"laborers  from  Southern  Europe,"  "certain  classes  of  Greeks,  Italians 
and  other  foreign  races,"  and  "foreigners  who  do  not  speak  English, 
French,  German,  or  Swedish."  The  reason  assigned  for  their  attitude 
toward  the  races  named  by  the  companies  which  stated  a  reason  was 
that  the  moral  hazard  of  insuring  individuals  of  these  races  was  too 
great  to  make  it  desirable  to  accept  business  from  them.  The  company 
which  referred  to  "certain  classes  of  Greeks,  Italians  and  other  foreign 
races"  as  undesirable  risks  charges  that  they  "often  take  insurance  for 


420 

speculative  purposes  rather  than  for  protection"  and  that  the  result  is 
the  evil  of  fraudulent  claims.  The  company  which  mentioned  "for- 
eigners who  do  not  speak  English"  or  one  of  the  other  languages  named 
explained  that  persons  in  this  class  often  feign  a  misunderstanding  of 
the  contract,  that  they  often  lack  "moral  sensibility/'  that  they  resort 
to  "substitution"  (that  is,  presumably,  they  attempt  to  collect  insurance 
for  injuries  or  illnesses  sulliered  by  uninsured  persons  under  policies  held 
by  other  persons),  and  that  physicians  of  foreign  nationalities  are 
sometimes  unscrupulous  in  making  out  certificates  concerning  accidental 
injuries  or  illnesses  for  members  of  their  own  race. 

Health  and  accident  insurance  companies  do  not,  like  life  insurance 
companies,  require  a  medical  examination  of  all  applicants  for  insur- 
ance but  limit  such  examinations  to  applicants  who  appear  from  their 
applications  or  other  evidence  to  be  physically  of  doubtful  desirability 
as  risks.  The  reasons  for  this  practice  have  been  set  forth  as  follows 
by  a  physician  who  has  served  as  a  medical  examiner  and  adjuster  for 
accident  insurance  companies: 

"Medical  examination  *  *  *  of  each  individual  applicant  for 
health  or  accident  insurance  has  not  found  favor  among  accident  com- 
panies for  several  reasons.  First,  because  of  the  expense,  the  addition 
of  two  or  three  dollars  in  examiners'  fees  to  the  cost  of  securing  a 
policy  appearing  to  the  underwriters  as  an  unnecessary  burden.  Second, 
owing  to  the  fact  that  accident  policies  are  based  upon  a  schedule  of 
warranties  or  statement  of  facts  in  the  application  which  becomes  the 
assured's  contract  with  the  company  and  upon  the  truth  of  which  the 
policy  is  issued,  medical  examination,  by  such  examiners  as  are  now 
available,  not  only  fails  to  help  materially  in  the  estimation  of  a  risk, 
but  may  prove  the  means  of  depriving  the  company  of  the  ability  to 
avail  itself  of  a  defense  of  breach  of  warranty  in  certain  cases  wh^ 
such  defense  might  prove  invaluable  in  the  prevention  of  imposition. 
Third,  the  adoption  of  universal  examinations  by  the  accident  com- 
panies as  now  practiced  in  life  insurance,  would  lead,  no  doubt,  to 
legislation  and  court  decisions  calculated  to  limit  the  right  of  cancella- 
tion by  the  companies,  for  it  is  but  reasonable  to  suppose  that  the 
inauguration  of  the  plan  of  examining  all  risks  would,  naturally,  be 
met  by  the  demand  that  the  policy  be  maintained  in  force  to  the  end 
of  the  term  for  which  it  was  originally  issued.  Fourth,  the  report  fur- 
nished by  the  average  examiner  seldom  conveys  to  the  experienced 
accident  underwriter  information  which  is  in  any  way  comparable  to 
what  he  can  acquire  through  bureau  records,  inspection  reports,  corre- 
spondence with  other  companies,  his  own  ability  to  read  between  the 
lines  of  an  application  and,  in  the  event  of  claim,  through  the  informa- 
tion obtained  from  the  claim  department  and  the  careful  scrutiny  of 
the  claim  papers.  Fifth,  owing  to  the  present  plan  of  appointing 
medical  examiners  *  *  *  their  reports  of  examinations  prove  of 
little  service  and  are  often  positively  ludicrous  when  seen  through  the 
eyes  of  the  experienced  home  office  underwriter.  Sixth,  the  general 
examination   of   applicants   for  accident   and  health   insurance   would 


421 

increase  the  difficulty  of  securing  new  business  and  lead  to  trouble  with 
the  agency  force."^- 

The  occupation  of  an  applicant  for  accident  or  health  insurance 
is  a  factor  of  prime  importance  in  determining  his  eligibility  for  insur- 
ance as  well  as  the  rate  of  premium  which  he  will  have  to  pay  if  he  is 
given  the  insurance  for  which  he  is  applying.  Comparatively  few 
occupations,  however,  are  classed  as"not  insurable;"  the  "Accident  In- 
surance Manual"  for  1918  so  classes  only  about  70  occupations  among 
the  three  or  four  thousand  included  in  its  classification  of  occupations.^^ 
The  other  occupations  are  graded  according  to  the  hazards  which  they 
are  believed  to  involve,  as  described  in  a  later  part  of  this  report,  and 
a  premium  rate  believed  to  be  sufficient  to  cover  the  hazard  is  adopted 
as  the  basic  rate  for  each  occupation.  This  rate,  it  should  be  noted, 
may  be  high  enough  for  certain  of  the  more  hazardous  occupations 
virtually  to  put  them  in  the  "not  insurable"  class  for  workingmen 
receiving  average  or  less  than  average  wages. 

Place  of  residence  may  be  an  important  factor  in  determining 
the  eligibility  of  an  applicant  for  health  insurance  but  so  far  as  the 
Commission  could  learn  casualty  companies  in  Illinois  do  not  as  a  rule 
discriminate  against  applicants  for  insurance  or  "prospects"  on  the 
ground  that  they  are  residents  of  a  particular  town,  city,  county,  or 
section  of  the  State  ^but  base  such  discriminations  as  they  may  make 
with  regard  to  residence  upon  conditions  which  exist  in  the  immediate 
environment  in  which  the  applicant  or  "prospect"  lives.  One  company, 
however,  informed  the  Commission  that  it  had  found  it  advisable  to 
restrict  its  health  insurance  business  in  East  St.  Louis  and  Granite 
City,  "both  from  a  health  and  moral  standpoint." 

In  order  to  prevent  "over-insurance"  and  the  temptation  to  simu- 
lation, malingering  and  fraud  which  over-insurance  is  likely  to  create, 
casualty  companies  require  applicants  for  health  or  accident  insurance 
to  state  in  their  applications  certain  details  as  to  other  health  and 
accident  insurance  which  they  may  carry  or  for  which  they  have  ap- 
plied. For  the  same  reason  the  companies  require  applicants  either 
to  state  in  their  applications  that  their  income  per  week  or  month 
exceeds  the  gross  amount  of  weekly  or  monthly  indemnity  payable 
under  all  policies  carried  by  them  or  to  specify  the  exact  amount  of 
their  income.  As,  a  further  safeguard  against  over-insurance  resulting 
from  the  taking  out  of  several  policies  in  the  same  company  or  in 
different  companies  many  policies  now  contain  the  following  provisions 
authorized  bv  the  Standard  Provisions  Law  (Insurance  Laws  of  the 
State  of  Illinois,  p.  131)  of  1915: 

"17.  If  the  insured  shall  carry  with  another  company,  corporation, 
association  or  society  other  insurance  covering  the  same  loss  without 
giving  written  notice  to  the  insurer,  then  in  that  case  the  insurer  shall 
be  liable  only  for  such  portion  of  the  indemnity  promised  as  the  said 

^W.  Edward  Magruder,  M.  D.,  in  chapter  on  "Medical  Examinations"  in  Dun- 
ham's Business  of  l7isurance.  Volume  II,  pp.  105-106. 

23  The  Spectator  Company's  Accident  Insurance  Manual  for  1918,  pp.  A3-A66. 
The  following-  are  typical  of  the  occupations  classified  as  "not  insurable" :  acid 
maker,  sulphuric,  user  or  custodian  of ;  army  officer,  war  service  ;  cartridge  maker ; 
common  sailor,  lake  or  ocean ;  dynamite  maker ;  electric  line  man ;  current  on ; 
jockey ;  prospect  mining. 


422 

idemnity  bears  to  the  total  amount  of  like  indemnity  in  all  policies 
covering  such  loss,  and  for  the  return  of  such  part  of  the  premium  paid 
as  shall  exceed  the  pro  rata  for  the  indemnity  thus  determined/' 

'^19.  If  a  like  policy  or  policies,  previously  issued  by  the  insurer  to 
the  insured  be  in  force  concurrently  herewith,  making  the  aggregate 

indemnity  for  loss  of  time  on  account  of  disability  in  excess  of  $ 

weekly,  the  excess  insurance  shall  be  void  and  all  premiums  paid  for 
such  excess  shall  be  returned  to  the  insured/' 

The  precautions  just  described  make  it  possible  for  the  insurance 
companies  to  limit  the  insurance  granted  applicants  in  the  great  ma- 
jority of  cases  to  an  amount  less  than  the  income  of  the  applicant; 
nevertheless,  it  is  stated  by  representatives  of  some  of  the  companies 
that  the  evil  of  over-insurance  has  not  yet  been  eliminated  and  that 
legislation  is  needed  to  control  the  evil. 

(6)   The  Cost  of  Casualty  Company  Insurance, 

The  merits  of  casualty  company  insurance  as  a  means  of  meeting 
the  need  of  wage-earners  for  health  and  accident  insurance  depend  to  a 
considerable  extent  upon  its  cost  to  the  insured.  The  cost  depends 
partly  upon  sickness  and  accident  hazards  and  partly  upon  the  business 
acquisition  expense,  the  expense  of  management  and  loading  for  profit. 
The  assets  of  a  prudently  managed  company  are  greatly  increased 
through  the  judicious  investment  of  its  funds.  The  premium  receipts 
and  investment  earnings  comprise  its  loss  and  expense  fund.  The  busi- 
ness of  the  casualty  companies  is  organized  upon  a  highly  competitive 
profit-seeking  basis.^"*  As  so  organized  the  business  depends  for  its 
sales  upon  the  employment  of  a  large  sales  force  who  possess  relatively 
high  qualifications  as  salesmen  and  can  therefore  command  relatively 
large  remuneration.  It  is  a  commonplace  among  insurance  agents 
that  health  and  accident  insurance  is  sold,  not  bought.  "Nobody  buys 
it  over  the  counter.  It  must  be  explained,  and  the  one  who  needs  it 
must  be  interested  and  convinced  of  that  which  really  is  essentially  a 
necessary  of  life.''^^ 

The  work  of  "explaining''  health  and  accident  insurance  to  the 
public  as  it  is  done  by  solicitors  for  the  casualty  companies  is  neces- 
sarily a  costly  business.  Most  persons  solicited  do  not  purchase  insur- 
ance; "statistics  show  that  one  out  of  every  ten  prospects"  properly 
approached  becomes  a  policyholder."^^  This  means  that  the  policy- 
holders of  an  insurance  company  must  pay  not  only  for  their  own 
education  as  to  the  merits  and  service  of  the  insurance  which  they  pur- 
chase but  also  for  the  expensive  attempts  made  to  educate  those  who 
do  not  buy.  A  considerable  part  of  the  so-called  educational  activities 
of  health  and  accident  insurance  agents  is  directed,  moreover,  not 
toward  the  diffusion  of  a  knowledge  of  the  general  principles  of  these 
classes  of  insurance  but  toward  the  creation  of  a  belief  that  the  policies 
of  this  or  that  company  are  better  bargains  than  the  policies  of  all  other 

"Exception  to  the  use  of  the  term  "profit-seeking"  should  perhaps  be  made  in 
the  case  of  the  mutual  companies.  The  term  is  not  employed  in  an  invidious  way. 
"Business"   is   primarily   "profit-seeking." 

»« The  Spectator's  Company's  Accident  Insurance  Manual,  for  1918,  p.  4. 

"  Same,  p.  5.     The  italics  are  the  present  writers. 


423 


companies.  There  is  much  duplication  in  the  efforts  of  agents;  persons 
who  purchase  health  and  accident  insurance  are  frequently  solicited 
several  times  by  each  of  several  agents  representing  different  companies 
having  practically  identical  policies  to  sell.^^  The  policyholders  pay  not 
only  for  the  genuinely  educational  activities  of  health  and  accident 
insurance  agents  but  also  for  their  purely  competitive  struggles  for 
"prospects."  The  competition  which  has  prevailed  in  the  health  and 
accident  insurance  business  in  the  past  has  been  advantageous  to  policy- 
holders in  a  number  of  respects.  It  has  been  a  potent  factor  in  liberal- 
izing policies,  although  not,  as  is  sometimes  assumed,  the  only  factor, 
and  it  may  have  hastened  the  present  development  of  the  business. 

The  following  table  compiled  from  recent  annual  reports  of  the 
Insurance  Superintendent  of  the  State  of  Illinois^^  shows  the  relation 
which  exists  between  the  premiums  paid  in  Illinois  to  the  casualty  com- 
panies and  the  losses  paid  by  them  in  Illinois. 


HEALTH  AND  ACCIDENT  INSURANCE  PREMIUMS  RECEIVED  AND  LOSSES 
PAID   IN  ILLINOIS   BY  CASUALTY  COMPANES,    1913-1917,   INCLUSIVE. 


Year. 

Premiums 
received. 

Losses  paid. 

Ratio 

of  premiums 

received  to 

losses  paid — 

per  cent. 

1913 

$  3,003,063 
3,013,418 
3, 150, 162 
3,489,330 

3,848,485 

$1,176,929 
1,367,665 
1,245,806 
1,509,777 
1,891,894 

39. 19 

1914 

45.39 

1915 .     . 

47.93 

1916 : 

43,27 

1917 

49.16 

Total  for  5  year  period,  1913-1917 

$16,504,458 

$7,192,071 

43.58 

The  comparison  here  made  is  not  entirely  fair.  With  an  expand- 
ing business  of  course  the  casualty  company  must  carry  a  reserve  to 
cover  its  heavier  claims  in  the  future.  Yet  this  reserve  requirement  is 
a  factor  of  minor  importance  in  explaining  the  disparity  between  pre- 
miums received  and  losses  paid  during  these  years.  The  acquisition 
expense  of  the  business  (largely  commissions  paid  agents)  accounts  in 
large  part  for  the  fact  that  the  casualty  companies  returned  to  health 
and  accident  policyholders  during  these  years  less  than  half  the  amount 
of  money  collected  from  them  in  premiums.  "The  agent^s  commission," 
the  Spectator  Company  says  in  its  "Accident  Insurance  Manual"  for 
1918  (page  7),  "is  usually  ten  or  twelve  times  as  much  as  the  com- 
pany's underwriting  profit."  The  same  authority  states  (page  4) 
that  "relatively  the  commissions  paid  to  the  sellers  of  Income  Insur- 
ance (and  that  is  what  health  and  accident  benefits  really  are)  are 
higher  than  are  paid  to  salesmen  in  any  other  legitimate  calling"  and 

"  "Remember  every  one  who  you  find  has  already  provided  himself  or  herself 
with  'Income  Insurance'  was  doubtless  solicited,  not  once  but  several  times,  by  not 
one  but  several  solicitors  lilce  yourself.  Many  policyholders  turned  down  a  dozen 
men  once  and  one  man  a  dozen  times,  until  the  rig'ht  salesman  sold  him  the  policy 
he  has  today."  The  Spectator  Company's  Accident  Insurance  Manual  for  1918,  pp. 
6-7. 

^Insurance  Reports  Illinois  1914,  Part  IIL  p.  6  ;  1915,  Part  III,  p.  6  ;  1916,  Part 
III,  p.  7  ;  1917,  Part  III,  pp.  7-8  ;  1918. 


424 


calls  attention  to  the  fact  that  "the  renewal  commissions,  that  is,  the 
compensation  paid  to  those  who  have  originally  sold  this  *  *  * 
necessary  of  life  and  who  have  'placed  the  annual  or  semi-annnal  re- 
newal of  the  contract/  are  constant — not  reduced,  as  in  other  forms  of 


insurance." 


Of  36  companies  filing  statements  with  the  Insurance  Department 
of  Wisconsin  in  1916,  20  paid  no  commissions  in  that  state  less  than 
25  per  cent;  11  of  the  20  paid  no  commissions  less  than  30  per  cent; 
and  5  paid  a  uniform  commission  of  35  per  cent.  One  of  the  20  com- 
panies paid  commissions  ranging  from  30  to  50  per  cent;  6  paid  com- 
missions ranging  from  25  to  35  per  cent;  and  one  paid  commissions 
ranging  from  25  to  33i^  per  cent.  Sixteen  companies,  as  indicated  by 
the  foregoing,  paid  some  commissions  of  less  than  25  per  cent  but  14 
of  these  companies  also  paid  some  commissions  of  25  per  cent  or  more — 
one  company  ranging  as  high  as  371/2  per  cent,  three  others  as  high  as 
35  per  cent,  two  others  as  high  as  33^3  per  cent,  and  three  others  a^ 
high  as  30  per  cent.  The  two  companies  remaining  in  the  sixteen  paid 
commissions  of  from  15  to  20  per  cent  plus  the  policy  fee,  which  may 
make  the  maximum  compensation  more  than  25  per  cent  in  most,  if 
not  all,  cases. 

The  lowest  commission  reported  by  any  of  the  thirty-six  companies 
first  mentioned  was  .71/2  per  cent.  This  was  paid  by  one  company  whose 
maximum  commission  is  35  per  cent.  Five  companies  report  minimum 
commissions  of  10  per  cent  with  maximum  commissions  of  30  per  cent 
or  more.  In  some  cases  the  minimum  commissions  mentioned  appear 
to  have  been  paid  for  the  writing  of  group  policies  but  the  Commission 
is  unable  to  state  whether  or  not  this  is  true  in  all  cases. 

The  explanation  of  the  great  variation  in  the  commissions  paid 
agents  is  to  be  found  partly  in  differences  in  the  territory  and  business 
of  different  agents  and  partly  in  the  exigencies  of  the  competition  for 
agents  which  prevails  among  casualty  companies.  The  following  quota- 
tions from  the  secretary  of  an  Illinois  company  will  suggest  the  nature 
of  this  competition: 

"The  easiest  thing  in  the  world  is  to  get  agents,  but  after  a  few 
weeks'  trial  it  dawns  on  the  new  manager  that  there  are  agents  and 
agents,  but  what  he  needs  is  men  who  will  produce  applications.  Some 
inducement  in  the  way  of  extra  compensation,  extended  territory,  of 
which  he  has  much  to  give,  or  the  held-out  proposition  of  advancement 
with  a  new  company  will  secure  from  agencies  of  larger  concerns  an 
initial  force  of  application  producers  for  a  small  company .''^^ 

"The  best  managed  company  with  the  most  loyal  force  of  agents 
will  frequently  find  that  its  business  is  being  transferred  to  another 
company,  for  it  is  one  thing  to  secure  a  good  agent,  another  to  hold 
him  against  all  the  allurements  offered  by  other  companies,  the  most 
enticing  of  which  is  an  excessive  compensation  for  his  work,  and  the 
manager  must  determine  from  the  agent's  past  record  whether  or  not 
he  can  meet  the  offer  of  the  othei:  company."*^ 

w  Alfred  E.  Forrest,  secretary  North  American  Accident  Insurance  Company,  in 
chapter  on  "Agency  Management"  in  Dunham's  Business  of  Insiirance,  Vol.  II,  p.  96. 
«Same.  pp.  100-101 


425 

Data  relating  to  net  premiums  collected  and  agents'  commissions 
and  brokerage  were  obtained  for  1917  from  the  statements  filed  by  57 
companies  with  the  Insurance  Department  of  this  State.  These  data, 
which  are  for  the  entire  business  of  the  companies  and  not  merely  for  the 
business  in  Illinois,  indicate  that  35  companies  reporting  health  in- 
surance separately  received  an  aggregate  of  $9,925,041.55  in  net  pre- 
miums and  paid  commissions  and  brokerage  totaling  $2,756,799.37, 
or  27.78  per  cent,  and  that  22  companies  reporting  health  and  accident 
insurance  combined  received  an  aggregate  of  $13,744,294  and  paid 
commissions  and  brokerage  totaling  $4,100,018.15,  or  29.8  per  cent. 

Health  and  accident  insurance  policies  differ  so  much  in  their  pro- 
visions that  it  is  difficult  to  make  a  satisfactory  summary  statement 
showing  the  accounts  of  the  premiums  charged  for  them.  At  the  same 
time  the  limitations  of  space  do  not  permit  detailed  descriptions  of 
policies  in  explanation  of  differences  in  premiums.  It  must  suffice 
therefore  to  say  that  a  commercial  disability  policy,  covering  both  ac- 
cident and  sickness  hazards,  which  provides  for  the  payment  of  a  princi- 
pal sum  of  from  $5,000  to  $7,500  and  a  weekly  indemnity  of  $25  is 
likely  to  cost  a  "select"  risk  about  $60  per  year,'^^  varying  more  or  less 
from  this  amount  according  to  the  features  included  in  the  policy.  It 
is  impossible  to  make  even  as  general  a  statement  as  the  foregoing  with 
respect  to  industrial  disability  policies  because  of  the  greater  variation 
in  their  provisions.  The  following  table,  which  shows  the  rates  charged 
by  a  certain  company  for  a  fairly  tj^ical  industrial  policy,  will,  how- 
ever, be  useful  for  purposes  of  illustration.*^     (Table  next  page.) 

It  will  be  observed  that  the  cheapest  policies  available  according 
to  this  table  cost  $3  the  first  month  and  $1  per  month  thereafter, 
making  a  total  of  $15  the  first  year  and  $12  every  year  the  policy  is 
continued  after  the  first  y§ar  until  age  51  is  reached.*^  In  Class  I  the 
premiums  mentioned  will  purchase  a  policy  which  provides  for  a  monthly 
benefit  of  $60  for  sickness  or  accident  and  a  principal  sum  of  $600  pay- 
able for  accidental  death  or  the  loss  of  any  two  limbs  or  both  eyes.  In 
Class  2  the  benefit  purchasable  for  the  premiums  mentioned  are,  re- 
spectively, $10  and  $100  less  than  in  Class  1  and  the  reductions  in  bene- 
fits continue  from  class  to  class,  although  not  always  at  the  same  rate, 
until  the  final  class  (Class  9)  is  reached.  In  Class  9  a  payment  of  $3 
the  first  month  and  $1  per  month  thereafter  will  pay  for  benefits  of  bnly 
$15  per  month  for  sickness  and  accident  disability  and  only  $100  for 
accidental  death  or  loss  of  any  two  limbs  or  both  eyes. 

In  explanation  of  the  difference  in  the  indemnities  provided  in  re- 
turn for  a  given  premium  it  should  be  said  that  the  classification  indicated 
in  the  table  reproduced  above  is  based  upon  occupations.  Applicants 
for  health  and  accident  insurance  are  classified  by  casualty  companies 
according  to  Avhat  is  assumed  to  be  the  relative  sickness  and  accident 

"See  the  Spectator  Company's  Accident  Insurance  Manual  for  1918  for  data 
concerning  policies  issued  by  the  principal  accident'  and  health  insurance  companies 
of  the  United  States. 

*2  The  rates  shown  apply  only  to  men  between  the  ages  of  18  and  50  inclusive. 
The  rates  for  men  between  the  ages  of  51  and  60  inclusive  are  computed  by  adding 
10  per  cent  to  the  rates  shown  for  each  year  over  50.  The  age  limit  is  60.  Women 
are  insurable  under  this  policy  for  an  indemnity  not  exceeding  $50  per  month 
and  in  no  case  covering  the  first  week  of  sickness  at  rates  one  class  lower  than  the 
classification  for  men  in  the  same  occupation. 

*'  See  preceding  note. 


426 


MONTHLY   PREMIUM   HEALTH   AND    ACCIDENT    POLICY- 

INTDEMNITIES   ANT)   RATES. 


-TABLE    OP 


(The  Rates  for  the  First  Month  Include  a  Policy  Fee  of  $2.) 

Indemnity  and  Cost  in  Indemnity  and  Cost  in 

Class  1.  Class  6. 


« 


Monthly 
accident 

and 

sickness 

indemnity. 


Accidental 

death 

or  loss 

of  any  two 

limbs  or 

both  eyes. 


$60.00 

70.00 

80.00 

90.00 

100.00 

125,00 


Cost  per  month. 


Initial 
or  first 
month. 


Suc- 
ceeding 
months. 


Class  2. 


Class  3. 


Class  4. 


"First 
week  of 

sick- 
ness" 

rider 
(addi- 
tional). 


$600.00 

$3.00 

$1.00 

700.00 

3.25 

1.25 

800.00 

3.50 

1..50 

900.00 

3.75 

1.75 

1,000.00 

4.00 

2.00 

1,500.00 

4.50 

2.50 

$0.60 

.70 

.80 

.90 

1.00 

1.25 


$  50.00 

$    500.00 

$3.00 

$1.00 

$0.50 

60.00 

600.00 

3.25 

1.25 

.60 

70.00 

700.00 

3.50 

1.50 

.70 

80.00 

800.00 

3.75 

1.75 

.80 

90.00 

900.00 

4.00 

2.00 

.90 

100.00 

1,000.00 

4.25 

2.25 

1.00 

120.00 

1,200.00 

4.75 

2.75 

1.20 

$40.00 

$400.00 

$3.00 

$1.00 

$0.45 

50.00 

500.00 

3.30 

1.30 

.55 

60.00 

600.00 

3.60 

1.60 

.65 

70.00 

700.00 

3.90 

1.90 

.80 

80.00 

800.00 

4.20 

2.20 

.90 

90.00 

900.00 

4.50 

2.50 

1.00 

$35.00 

$3.50.00 

$3.00 

$1.00 

$0.45 

40.00 

400.00 

3.20 

1.20 

.50 

50.00 

500.00 

3.50 

1.50 

.60 

60.00 

600.00 

3.85 

1.85 

.70 

76.00 

700.00 

4.20 

2.20 

.80 

80.00 

800.00 

4.50 

2.50 

.90 

Class  5. 

$30.00 

$300.00 

$3.00 

$1.00 

$0.40 

35.00 

350.00 

3.25 

1.25 

.50 

40.00 

400.00 

3.50 

1.50 

.60 

50.00 

500.00 

3.90 

1.90 

.70 

60.00 

600.00 

4.35 

2.35 

.80 

Accidental 

death 

or  loss 

of  any  two 

limbs  or 

both  eyes. 

Cost  per  month. 

Monthly 
Accident 

and 

sickness 

indemnity. 

Initial 
or  first 
month. 

Suc- 
ceeding 
months. 

"First 
week  of 
sick- 
ness" 
rider 
(addi- 
tional). 

$25.00 
30.00 
35.00 
40.00 
50.00 
60.00 

$250.00 
300.00 
350.00 
400.00 
500.00 
600.00 

$3.00 
3.25 
3.50 
3.75 
4.25 
4.75 

$1.00 
1.25 
1.50 
1.75 
2.25 
2.75 

$0.35 
.40 
.50 
.60 
.70 
.80 

$15.00 
20.00 
25.00 
30.00 
35.00 
40.00 
50.00 


Class  7. 


$20.00 

$100.00 

$3.00 

$1.00 

$0.30 

25.00 

100.00 

3,30 

1.30 

.35 

30.00 

150.00 

3.60 

1.60 

.40 

35.00 

150.00 

3.90 

1.90 

.50 

40.00 

200.00 

4.20 

2.20 

.60 

50.00 

250.00 

4.75 

2.75 

.70 

60.00 

300.00 

5.35 

3.35 

.80 

Class  8, 


$20.00 

$100.00 

$3.00  i 

$1,00 

25.00 

100,00 

3.40 

1,40 

30.00 

100.00 

3,75 

1.75 

35.00 

100.00 

4.10 

2.10 

40.00 

100.00 

4.50 

2.50 

50.00 

100.00 

5.00 

3.00 

Class  9. 


$100.00 

$3.00 

$1.00 

100.00 

3.50 

1,50 

100.00 

4,00 

2.00 

100.00 

4.50 

2,50 

100.00 

5.00 

3.00 

100.00 

5,50 

3,50 

100.00 

6.50 

4,50 

$0,30 
,35 
.40 
.50 
,60 
.70 


$0,25 
,30 
.35 
.40 
.50 
.60 
.70 


427 

hazards  of  the  occupations  in  which  the}^  are  engaged.**  Class  I  in 
the  table  includes  occupations  which  are  believed  to  be  less  hazardous. 
If  all  wage-earners  had  occupations  listed  in  Class  1  or  in  the  first 
two  or  three  classes  the  problem  of  health  insurance  would  be  a  less 
difficult  one  than  it  is,  for  adequate  health  insurance  would  then  be 
more  nearly  within  the  reach  of  the  average  wage-earner.  But  the  first 
two  classes*^  are  almost  entirely  made  up  of  the  occupations  of  business 
and  professional  men,  their  salaried  employees  and  certain  salaried  em- 
ployees of  the  federal,  state,  or  city  governments.  Class  3  is  almost 
entirely  made  up  of  the  occupations  of  business  and  professional  men, 
salaried  employees  and  skilled  workmen.  The  occupations  of  the  great 
majority  of  wage-earners  are  classified  in  Classes  4  to  9  inclusive,  which 
require  the  highest  health  and  accident  insurance  premiums.  In  general 
it  ma}"  be  said  that  health  and  accident  insurance  premiums  are  highest 
for  those  occupations  which  are  most  poorly  remunerated.  The  follow- 
ing table  showing  the  classification  of  certain  occupations  in  the  Specta- 
tor Company^s  "Accident  Insurance  Manual"  for  1918  is  offered  in 
support  of  this  conclusion.*^ 

**  Accident  hazards  appear  to  have  greater  weight  as  a  rule  than  sickness 
hazard?  in  determining  the  classification  of  a  given  occupation. 

*^  The  data  here  presented  with  respect  to  the  classification  of  occupations  are 
derived  from  the  classification  in  the  Spectator  Company's  Accident  Insurance 
Manual  jor  1918. 

^«  The  Manual  explains  its  classification  as  follows    (p.  A2)  :     "Each  $1,000  of 
Insurance  carries  with  it  $5  weekly  indemnity  unless  otherwise  specified.     *     *     *. 
Occupations    are   classified    by    letter,    numeral    and    title,    following,   prevailing 
practices  of  various  companies. 

The  classification  "A  Special"  is  herein  entitled  "Select." 
The  classification   "Extra  Medium"   is   herein   entitled   "Special." 
The  classification  "Sub  Standard"  is  herein  entitled  "Hazardous." 
The  classification  "Perilous"  is  herein  entitled  "Special  Hazardous." 
The  classification   "Extra  Peril"   is  herein   entitled   "Extra   Special  Hazardous." 
The   numeral    2,    herein    adopted,    signifies   classification    "BS,"    or    "Extra   Pre- 
ferred." 

As  used  in  this  Manual,  the  following  table  shows  the  designations  which 
signify  the  same  classificaton  of  risks. 

Al   Select.  D  4   Medium.  F7  Extra  Hazardous. 

B2  Preferred.  DS5  Special,  G8  Special  Hazardous. 

C3  Ordinary.  E  6  Hazardous.  H9  Extra  Special  Hazardous. 

Limit  of 
Occupation.*  Class.  risk. 

Agricultural  laborer  (farm  hand) F     7    Extrahazardous..  $  1,000 

Asphalt  floor  or  street  layer DS  5    Special 1, 500 

Baker,  driving  wagon D    4    Medium 2,000 

Baker,  shop  and  counter  work  only C     3    Ordinary 3,000 

Beef  handler,  in  warehouse D    4    Medium 1,500 

Boiler  maker DS5    Special 1, 500 

Can  maker D    4    Medium 2,000 

Can  maker,  not  using  die t C     3    Ordinary 3,000 

Cannery,  packer,  solderer  or  boiler C     3    Ordinary 2,000 

Car  builder,  shoj)  work  only DS  5    Special 2,000 

Car  repairer,  in  yards E     6    Hazardous 1,500 

Car  repairer,  shop  work  only DS5    Special 2, 000 

Carpenter,  framing,  not  bridge  carpenter E     6    Hazardous 2,000 

Carpenter,  shop  work,  using  machinery E    6    Hazardous 1,500 

Carpenter,  inside  or  shop  work  only,  not  using  machinery D    4    Medium 2,500 

Cigar  or  cigarette  maker C     3    Ordinary 2,000 

Delivery  wagon  driver,  light  parcels  only D    4    Medium 2,000 

Drayman,  not  teamster  in  woods E    6    Hazardous 1,500 

Engineer,  stationary  engine D    4    Medium 2,500 

Gasfitter D    4    Medium 2,000 

Grocery  plerk,  delivering  goods  or  soliciting  orders  with  wagon.. D    4    Medium 2,000 

Groceryclerk,  not  delivering  foods  or  soliciting  orders  with  wagonC     3    Ordinary 3,000 

Grocery  clerk,  counter  duties  only  (large  city  store) B    2    Preferrea 3,000 

*  In  considering  this  table  the  large  proportion  of  wage-earners  who  fall  under 
the  classification  of  common  laborer  must  be  borne  in  mind.  The  fact  that  the 
occupations  of  most  business  men,  professional  men  and  salaried  persons  fall  under 
the  first  three  classifications  shown  in  Note  2,  p.  53,  also  re-inforces  the  statement 
that  in  general  health  and  accident  insurance  premiums  are  highest  for  those  occu- 
pations which  are  most  poorly  renumerated. 


428 


f  It  is  evident  from  the  forgoing  data  that  the  purchase  of  health  and 
accident  insurance  from  a  casualty  company  imposes  a  relatively  heavy 
financial  burden  on  the  wage-earner — a  burden  which  is,  in  fact,  so 
heavy  that  the  great  mass  of  wage-earners  do  not  purchase  the  insurance 
at  all.  It  is  therefore  in  point  to  enquire  if  it  is  not  possible  to  reduce 
the  premiums  on  this  insurance  to  a  level  which  will  place  the  protection 
within  the  reach  of  wage-earners  generally  and  induce  them  to  purchase 
it  in  amounts  adequate  to  their  needs.*^ 

In  considering  this  question  it  is  necessary  to  divide  the  premium 
into  two  parts^the  net  premium  and  the  loading — and  to  consider  each 
part  separately.  The  net  premium  of  a  policy  is  the  amount  assumed 
to  be  necessary  with  accrued  interest  to  pay  that  polices  share  of  the 
accident  and  sickness  claims  which  the  insurance  carrier  must  meet. 
The  loading  is  the  amount  added  to  the  net  premium  to  provide  the 
margin  from  which  the  company  is  supposed  to  pay  its  costs  of  doing 
business  and  dividends  on  its  stock  (if  it  is  a  stock  company)  and  pro- 
vide for  contingencies.  In  practice  a  company  may  pay  part  of  its  costs 
of  doing  business  and  part  of  its  dividends  from  savings  in  the  net 
premiums  it  collects  arising  from  a  sickness  and  accident  experience 
which  is  more  favorable  than  the  experience  assumed  in  calculating  the 
net  premiums. 

The  net  premium  depends  upon  the  sickness  and  accident  experience 
and  the  rate  of  interest  on  invested  funds  assumed  by  the  company  in 
calculating  its  rates.  If  this  experience  corresponds  fairly  closely  with 
the  actual  experience  of  the  company  the  net  premium  can  only  be  re- 
duced by  increasing  the  rate  of  interests  on  investmenis  or  decreasing 
the  amount  and  severity  of  the  disability  from  accidents  and  sickness 
suffered  by  policyholders  of  the  company.  The  possibility  of  decreasing 
the  amount  and  severity  of  disability  from  sickness  among  wage-earners 
is  considered  elsewhere  in  this  report.*^ 

An  important  question  is,  cannot  the  acquisition  cost  which  is 
such  an  important  factor  in  determining  the  cost  of  this  insurance,  be 
materially  reduced. 

Several  answers  have  been  suggested  to  this  question.  One  of  these, 
the  group  insurance  plan  under  which  wage-earners  are  insured  in  groups 
by  their  employers  instead  of  individually  at  their  own  expense  and  at 

Hat  or  cap  maker C     3»  Ordinary $ 

Hod  carrier E    6    Hazardous 

Laborer,  common  (state  nature  of  work) E    6    Hazardous 

Lathe  hand DS  5    Special...."!!;!!! 

Laundryman c     3    Ordinary 

Machinist DS  5    Special. 

Molder,  pourer E     6 

Holder,  not  pourer : !!!! DS5 

Motorman ,  street  railroad : ! ! ! ! ! D    4 

Packing  house  employees  (8  occupations) C     3 

Packing  house  employees  (15  occupations) D    4    Medium.!!!!!!!!!     l!  500-3,' 000 

Packing  house  employees  (5  occupations) DS  5    Special 1^000-2^000 

"The  suggestion  made  in  some  quarters  that  the  general  wage  level  be  in- 
creased so  that  wage-earners  may  be  able  to  purchase  casualty  company  insurance 
SL^f1.?Kff^^?o^°y  '^  interesting  but  of  little  value  in  view  of  the  fact  that  no 
?S|gesttoi  increasing  the  general   level   of  wages   is   presented   with  the 

*'  Part  I,  Ch.  I,  Section  9  ;  also  Ch,  II. 


2,000 
1,000 
1,000 
2,000 
2,000 
2,500 
2,000 
2,000 
2,000 
Ordinary 2,000-5,000 


6    Hazardous . 


Special.. 
Medium. 


429 

premiums  reduced  in  view  of  the  reduced  cost  of  getting  and  handling 
the  business,  will  be  considered  in  the  report  on  group  insurance.*^ 

Another  suggestion  is  that  health  insurance  be  sold  by  life  insur- 
ance companies  in  connection  with  life  insurance.  Mr.  Miles  M.  Dawson 
in  urging  this  plan  argues  that  insurance  against  loss  of  time  by  sick- 
ness or  accident  "is  essentially  a  part''  of  life  insurance  and  that  "in 
connection  with  a  life  insurance  policy,  it  is  possible  to  furnish  at  a 
much  lower  cost,  because  of  lower  expense  in  the  payment  of  commis- 
sions, indemnity  for  the  whole  course  of  the  disability,  renewable  with- 
out increase  of  premium  and  at  the  option  of  the  insured.^'  The  policies 
sold  by  casualty  companies,  Mr.  Dawson  says,  "are  subject  to  *  *  * 
serious  objection'^  among  which  is  the  fact  that  "the  premiums  contain 
a  large  surcharge  of  expense,  the  same  commission  being  paid  to  agents 
each  year.'^^^ 

A  third  suggestion  for  reducing  the  cost  of  providing  health  and 
accident  insurance  is  that  the  casualty  companies  sell  these  forms  of 
insurance  on  the  level  premium,  non-cancellable,  continuing  policy 
plan  instead  of  on  the  annual  or  monthly  contracts  now  used.^^  If  this 
suggestion  were  adopted  policies  would  be  offered  which  would  continue 
in  effect  until  the  insured  reached,  say,  age  65  and  on  which  the  annual 
or  monthly  premium  would  remain  the  same  throughout  the  life  of  the 
policy.  The  advantages  of  the  plan  as  respects  the  cost  of  insurance 
would  appear  in  the  saving  in  the  renewal  commissions  paid  agents, 
'because,  as  is  the  case  in  life  insurance,  the  agent  would  have  little,  if 
anything  to  do  in  the  premises;  a  loading  of  30  per  cent  (of  the  net 
premium)  should  be  ample  to  meet  all  proper  expenses."^^  One  of  the 
leading  advocates  of  this  plan  asserts  that  it  is  "sure  to  come — probably 
sooner  than  many  of  us  now  think  possible — ^and  it  will  give  tremendous 
impetus  to  the  business  transacted  by  the  companies.'^^^ 

Several  attempts  have  been  made  to  apply  the  second  plan  in  whole 
or  in  part.  In  the  early  history  of  industrial  life  insurance  in  the 
United  States  insurance  against  sickness  was  combined  with  insurance 
against  death.  This  experiment  was  a  failure.  "Experience  proved,^' 
says  Mr.  John  F.  Dryden,  late  president  of  the  Prudential  Insurance 
Company  of  America,  in  explanation,^^  "that  under  present  conditions 
the  operations  of  an  Industrial  company  must  of  necessity  be  limited  to 
the  assurance  of  a  sum  certain  payable  at  death,  while  the  assurance 
of  a  stipulated  sum  during  sickness  can  only  with  safety  be  transacted, 
and  then  only  in  a  limited  way,  by  fraternal  organizations  having  a 
perfect  knowledge  of  and  complete  supervision  over  the  individual 
members.^^     *     *     *     Accordingly,  after  a  few  years  the  business  was 

*9  See  Part  II,  Special  Report  IX. 

"The  quotations  in  this  paragraph  are  taken  from  pp.  244-245  of  The  Business 
of  Life  Insurance,  published  in  1905,  by  Miles  M.  Dawson,  Consulting  Actuary, 
Actuary  of  the  New  York  Legislative  Committee  for  the  Investigation  of  Life  In- 
surance, etc.  Mr.  Dawson's  other  objections  to  casualty  company  health  and 
accident  insurance  are  stated  later  in  this  report. 

"iReinard  S.  Keelor,  M.  D.,  Liability  Underwriter  United  States  Casualty  Com- 
pany and  former  secretary  Philadelphia  Casualty  Company,  in  chapter  on  "Sickness 
Insurance"  in  Dunham's  Business  of  Insurance,  Vol.  II,  pp.  123-126. 

"Same,  p.  126. 

53  Same,  p.  124. 

"  Addresses  and  Papers  on  Life  Insurance  and  Other  Subjects,  by  John  F.  Dry- 
den, pp.  31-32  and  38. 

^  Mr.  Dryden  overlooked  the  commercial  success  of  a  number  of  casualty  com- 
panies in  the  field  of  health  insurance  at  the  time   (1903)   he  wrote  this  statement. 


430 


limited  to  the  insurance  of  a  sum  certain  payable  at  death/'  Accident 
insurance  which  provides  indemnities  against  accidental  death  is  a 
"limited  form  of  life  insurance/'  as  it  has  been  called,  as  is  also  the 
relatively  small  amount  of  health  insurance  sold  in  Illinois  on  policies 
which  provide  for  the  payment  of  funeral  benefits.^^  Attention  should 
also  be  called  to  the  fact  that  some  life  companies  engage  in  the  health 
and  accident  business.  A  few  life  insurance  companies  now  offer  com- 
bination policies  providing  insurance  against  death,  sickness  and  acci- 
dent, but  it  would  appear  that  only  a  few  such  policies  have  been  written. 
Another  suggestion  is  that  if  this  insurance  was  written  on  a  few 
standardized  forms  provided  by  law,  there  would  be  a  clearer  under- 
standing of  rights  by  the  insured  and  less  dissatisfaction  over  the  dis- 
position of  claims.  A  greater  degree  of  satisfaction  on  the  part  of  the 
insured,  however  secured,  would  increase  the  volume  of  insurance  written 
by  the  agent  and  reduce  the  acquisition  cost  and  the  premium  charge. 

(7)  Possibilities  of  Casualty  Company  Insurance  as  a  Solution  for  the 
Health  Insurance  Problem  of  the  Wage-earner. 

It  should  be  evident  from  the  preceding  pages  of  this  discussion 
that  casualty  company  insurance  has  not  yet  reached  a  stage  of  develop- 
ment where  it  can  be  accepted  as  an  agent  of  great  importance  in  meet- 
ing the  need  of  the  great  body  of  wage-earners  in  Illinois  for  health 
insurance.  Nevertheless  casualty  company  insurance  may  have  possi- 
bilities of  further  development  which  may  make  it  more  serviceable  in 
this  particular.  The  fact  that  this  might  prove  to  be  true  is  indeed  the 
principal  reason  which  led  the  Commission  to  make  a  detailed  investi- 
gation of  this  type  of  insurance. 

Casualty  company  health  insurance  is  a  comparatively  new  form  of 
insurance.  Although  a  number  of  companies  were  organized  in  the 
United  States  for  the  purpose  of  writing  health  insurance  prior  to 
1850,  when  two  of  these  companies  were  authorized  by  the  legislature  of 
Massachusetts  to  write  accident  insurance  as  well  as  health  insurance," 
health  insurance  as  it  is  sold  to-day  by  casualty  companies  developed  as  a 
feature  of  accident  insurance.  The  pioneer  health  insurance  com- 
panies appear  to  have  failed  and  retired  from  both  the  health  and  acci- 
dent business  because  of  poor  selection  of  risks,  loosely  worded  contracts 
and  serious  errors  in  the  calculation  of  premium  rates.^^  The  accident 
insurance  business  was  revived  in  the  1860's  following  the  chartering  in 
Connecticut  of  the  Travelers  Insurance  Company  in  1863  and  the 
appearance  shortly  after  of  a  number  of  rival  companies^^  and  it  has 
had  a  continuous  development  since  then.  "The  business  of  sickness 
insurance  in  the  United  States  (after  the  pioneer  period  referred  to 
above)  lapsed  into  a  condition  of  innocuous  desuetude,  relieved  only  by 
the  sporadic  attempts  of  a  few  life  insurance  companies  in  the  decade 
following  1860,  to  create  an  interest  in  such  insurance,  until  about  1894, 
when  a  little  rider,  covering  only  eight  zymotic  diseases  and  attached 


66 


See  p.   483. 


87  Sylvester  C.  Dunham,  former  president  of  the  Travelers  Insurance  Company, 
in  chapter  entitled  "Historical  Sketch"  in  Dunham's  Business  of  Insurance,  Vol.  II, 
pp.  8-9  and  Remard  S  Keelor,  M.  D.  in  chapter  on  "Sickness  Insurance"  in  the 
same  work.  Vol.  II,  p.  121. 

"Same  reference,  pp.  11  and  121,  respectively. 

"Same  reference,  pp.  11-15. 


431 

as  an  adjunct  to  accident  policies,  made  its  appearance,  and  from  this 
rider,  by  the  process  of  gradual  evolution,  sickness  insurance  as  we  now 
know  it,  took  its  rise.  Beginning  cautiously  (and  very  properly  so), 
with  a  separate  policy  covering  a  limited  number  of  diseases  *  *  * 
stress  of  competition  soon  caused  the  list  of  named  diseases  to  be  grad- 
ually extended,  until  finally  the  policy  covering  any  sickness  made  its 
appearance/'^^ 

Accident  insurance  in  the  United  States  thus  has  a  continuous 
history  of  more  than  half  a  century  while  health  insurance  has  a  con- 
tinuous history  about  half  as  long.  The  development  of  these  two  types 
of  insurance  is  characterized  by  an  increasing  liberalization  of  policy 
contracts,  the  growth  of  an  improved  technique  for  the  prevention  and 
detection  of  malingering  and  simulation  and  the  placing  of  the  health 
and  accident  insurance  business  generally  upon  a  sound,  profit-making 
basis  for  the  investor. 

Policy  contracts  have  been  liberalized  in  two  ways:  first,  by  the 
inclusion  of  more  generous  and  more  numerous  indemnities — a  matter 
which  has  been  sufficiently  discussed  in  preceding  pages — and  secondly, 
by  the  elimination,  by  certain  companies  which  formerly  used  them, 
of  provisions  designed  unfairly  to  discourage  the  presentation  of  claims 
or  prevent  their  collection  when  presented. 

The  president  of  a  casualty  company,  writing  six  or  seven  years 
ago,  describes  the  unfair  contracts  formerly  used  by  some  of  the  com- 
panies  selling   industrial   health    and    accident   insurance    as   follows : 

^'The  primary  object  of  this  sort  of  protection  was  and  should  be, 
to  provide  an  income  to  the  wage-earner  when  his  wages  are  cut  off  by 
unfortuitous  circumstances.  The  principal  object  of  the  first  under- 
writers seemed  to  be  the  production  of  something  that  could  be  sold. 
Therefore,  in  order  to  furnish  a  marketable  commodity  they  sought  to 
issue  a  policy  at  a  popular  price  and  the  almost  universal  price  was 
$1  per  month.  The  attempt  was  made  to  confine  the  benefits  promised 
to  what  a  dollar  would  pay  for,  but  lack  of  experience  made  it  prac- 
tically impossible  to  determine  with  any  degree  of  accuracy  just  what 
could  be  promised  for  such  a  premium,  having  in  mind  the  great 
diversity  in  the  occupations  and  habits  of  the  insured;  and  as  the  com- 
petition increased,  greater  and  more  fanciful  promises  were  made  until 
the  policy  became  more  of  a  literary  and  insurance  monstrosity  than 
the  product  of  scientific  underwriting.  As  one  company  would  add  a 
liberal  provision  to  its  policy,  the  other  companies  would  try  to  outdo 
it,  until  finally  the  policies  were  so  prepared  that  it  would  require  a 
mathematician  to  determine  what,  if  anything,  a  policyholder  was  en- 
titled to  in  case  of  a  claim.  The  policy  would  provide  for  a  certain 
amount  of  indemnity  in  case  of  accident  or  sickness,  then  in  some  hidden 
clause  there  would  be  a  provision  that  only  a  fraction  of  the  amount 
promised  would  be  payable  under  certain  conditions  and  a  different 
fraction  under  slightly  different  conditions,  and  so  on,  imtil  a  study 
of  the  policy  forms  in  general  led  one  into  a  maze  from  which  he  was' 
only  able  to  extricate  himself  by  giving  the  matter  up  in  disgust.  This 
condition  existed  until  within  a  very  few  years,  when  by  the  aid  of 

*"  Keelor,  in  Dunham's  Business  of  Insurance,  Vol.  II,  pp.  121-122. 


432 


accumulated  experience,  the  disadvantage  and  undesirability  of  these 
added  curiosities  became  apparent  and  it  was  soon  demonstrated  that 
the  companies  must  prevent  the  loss  which  a  liberal  construction  of  such 
policies  would  entail.  This  was  attempted  by  cutting  down  the  claims 
and  refusing  payment  on  the  slightest  technicality/'^^  if 

The  Standard  Provisions  laws  enacted  in  a  number  of  states  have 
been  a  material  aid  in  eliminating  unfair  and  misleading  provisions  in 
accident  and  health  insurance  contracts  and  in  standardizing  the  pro- 
visions which  are  now  used.  Limitations  of  time  and  space  forbid  a 
detailed  discussion  of  the  Standard  Provisions  Law  of  Illinois/^  but 
the  main  outlines  of  the  law  may  be  briefly  described.  This  law  pro- 
vides, among  other  things,  that  all  accident  and  health  policies  "shall 
contain  certain  standard  provisions,''  fifteen  in  number,  the  phraseology 
of  which  is  set  forth  in  the  law  and  which  must  be  followed  exactly 
word  for  word.  These  provisions  prescribe  the  documents  which  are 
to  constitute  the  contract  of  insurance,  the  method  of  reinstating  the 
policy  after  lapse,  the  time  within  which  the  insured  must  file  notice 
of  claim  with  the  company,  what  shall  constitute  sufficiency  of  notice 
of  claim  with  the  company,  the  method  and  time  within  which  the 
insured  must  furnish  proof  of  loss  to  the  company,  the  method  and 
time  within  which  the  company  must  pay  the  indemnities  due  the 
insured,  the  rights  of  the  beneficiary  under  the  policy,  and  the  time 
within  which  suit  may  be  brought  upon  the  policy.  The  required 
standard  provisions  also  define  the  right  of  the  company  to  examine 
the  person  of  the  insured  during  the  pendency  of  a  claim  and  to  make 
an  autopsy  in  case  of  death  and  the  right  of  the  insured  upon  change 
to  a  less  hazardous  occupation  to  demand  and  obtain  the  cancellation 
of  his  policy  and  the  return  of  the  unearned  premium  upon  it. 

In  addition  to  the  standard  provisions  which  all  accident  and  health 
policies  must  contain,  the  Standard  Provisions  Law  of  Illinois  prescribes 
certain  "optional  standard  provisions"  which  must  be  used  if  the  policy 
contains  any  provisions  governing  the  subject  matter  of  these  so-called 
optional  provisions.  The  section  of  the  law  which  prescribes  the  optional 
provisions  reads  in  part  as  follows: 

"No  such  policy  shall  be  so  issued  or  delivered  which  contains  any 
provision  (1)  relative  to  cancellation  at  the  instance  of  the  insure/; 
or,  (2)  limiting  the  amount  of  the  indemnity  to  a  sum  less  than  the 
amount  stated  in  the  policy  and  for  which  the  premium  has  been  paid; 
or,  (3)  providing  for  the  deduction  of  any  premium  from  the  amount 
paid  in  settlement  of  the  claim;  or,  (4)  relative  to  other  insurance  by 
the  same  insurer;  or,  (5)  relative  to  the  age  limits  of  the  policy,  unless 
such  provisions  which  are  hereby  designated  as  optional  provisions,  shall 
be  in  the  words  and  in  the  order  in  which  they  are  hereinafter  set  forth, 
but  the  insurer  may  at  its  option  omit  from  the  policy  any  such  optional 
standard  provision."®^ 

•*  Reinhold  R.  Koch,  president  American  Assurance  Company,  in  chapter  on 
"Industrial  Accident  and  Health  Insurance"  in  Dunham's  Biisiness  of  Insurance, 
Vol.  II.  pp.  138-139. 

^Insurance  Laws  of  the  State  of  Illinois,  1917,  pp.  125-134.  This  law  went 
into  effect  January  1,   1916. 

**  Insurance  Laws  of  the  State  of  Illinois,  1917,  p.  130,  section  4. 


433 

The  problems  arising  from  fraudulent  claims,  malingering  and 
the  simulation  of-  injuries  and  disability  are  serious  problems  which 
will  have  to  be  faced  under  any  form  of  health  and  accident  insurance 
so  long  as  human  nature  remains  substantially  as  it  is  at  present  con- 
stituted. The  casualty  companies  have  had  valuable  experience  in  deal- 
ing with  these  problems  and  this  experience  should  be  utilized  in  any 
attempt  that  may  be  made  to  secure  a  more  general  use  of  health  and 
accident  insurance  by  wage-earners  or  others.  The  nature  of  the  prob- 
lems, some  of  the  means  used  by  casualty  companies  in  meeting  them 
and  other  means  which  have  been  proposed  may  be  set  forth  most  accu- 
rately by  quoting  from .  statements  made  by  officials  of  casualty  com- 
panies who  have  written  on  the  subject: 

"Policies  have  been  obtained  with  the  intent  to  defraud,"  says  the 
president  of  a  casualty  company.  "Few  companies  have  remained  im- 
mune to  these  attempts.  *  *  *  So  skillful  were  some  that  they 
ended  in  success.  At  times,  murder  and  suicide  enter  into  the  scheme, 
but  usually  it  takes  the  form  of  self-mutilation.  Strange  as  it  may  seem 
to  a  normal  mind,  men  actually  do  shoot  off  a  hand  or  a  foot,  or  destroy 
the  sight  of  an  eye  for  the  sole  purpose  of  collecting  indemnity  from  an 
accident  insurance  company.  *  *  «  Ii^  many  instances  persons  of 
eminent  respectability  make  excessive  claims  utterly  oblivious  of  inten- 
tional wrong-doing.  They  may  be  charitably  designated  as  ^uncon- 
scious malingers.^  Some  otherwise  fair-minded  persons  pervert  the 
meaning  and  intent  of  the  contract  provisions  and  maintain  that  their 
claims  should  be  paid  because  to  disapprove  them  is  to  impeach  their 
integrity.  Not  infrequently  the  agent  who  secured  the  risk  writes  to 
his  company  that  his  business  will  be  ruined  if  a  particular  claim  is  not 
paid;  while  many  insurants  and  some  agents  imagine  that  to  whisper 
the  words,  ^man  of  influence  in  the  community,'  is  sufficient  to  cause 
the  company  to  abandon  well  settled  principles  in  claim  adjustment. 
It  must  not  be  thought  *  *  *  ^^lat  the  percentage  of  dishonest 
claims  is  large;  quite  the  contrary;  the  overwhelming  majority  of  claims 
presented  are  honest.  Yet  the  dishonest  and  exorbitant  claims  cost 
time  and  money ."^* 

"The  most  important  single  element  in  the  consideration .  of  acci- 
dent and  health  claims  by  insurance  companies  is  the  unfavorable  atti- 
tude of  the  attending  physicians,  as  they  alone  can,  without  injvistice, 
be  held  responsible  for  inspiring  nearly  all  of  the  claims  which  prove 
troublesome  to  insurance  companies,  either  through  suggestion  or  as  a 
result  of  their  strong  desire  to  please  rather  than  arouse  the  opposition 
of  those  from  whom  they  gain  their  livelihood.  The  extremes  to  which 
medical  men  of  unquestioned  standing  and  ability  will  go  in  order  to 
assist  their  patients  in  the  collection  of  claims  against  insurance  com- 
panies is  really  appalling.  In  many  instances,  claims  which  would  not 
come  to  the  attention  of  the  companies,  except  through  the  assistance 
and  ingenuity  of  the  family  doctor,  are  so  well  prepared  to  meet  the 

"*  Edson  S.  Lott,  president  U.  S.  Casualty  Company,  in  chapter  on  "Premium 
Rates"  in  Dunham's  Bit,siness  of  Insurance,  Vol.  H,  pp.  49-50.  It  will  be  noted  that 
Mr.  Lott  is  speaking-  of  experience  with  accident  insurance  only. 

—28  H  I 


434 


requirements  of  the  policy  that  many  of  them  are  paid  by  the  claim 
departments  without  question. 

"It  is  only  fair  to  say,  in  behalf  of  the  attending  physician  that, 
although  he  is  to  a  greater  or  less  degree  responsible  for  every  case  in 
which  the  companies  are  imposed  upon  by  claimants,  under  accident 
or  health  policies,  he  almost  always  renders  this  service  to  his  patient 
without  the  thought  of  any  direct  financial  benefit  to  himself.  He 
makes  the  mistake  either  through  his  desire  to  accommodate  his  patient 
and  avoid  the  trouble  of  a  conflict  with  him  over  what  appears  to  be 
trivial  matter,  or  he  has  learned  by  experience  that,  in  order  to  hold 
his  practice,  he  must  comply  with  the  wishes-  of  his  patients  in  the 
filling  of  claim  blanks,  wherever  possible,  under  penalty  of  having 
them  go  to  some  competitor  who  will  give  them  the  service  which  they 
desire.     *     *     * 

"The  attorneys  who  prey  upon  insurance  companies  and  corpora- 
tions and  are  conspicuous  for  their  activity  both  in  securing  the  claims 
of  individuals  for  collection  and  in  the  methods  to  which  they  resort 
for  the  accomplishment  of  their  purposes,  could  not  exist  without  the 
aid  of  the  medical  men  for,  without  the  certain  knowledge  that  they 
can  always  find  one  or  more  physicians  in  each  community  willing  to 
go  on  the  witness  stand  in  support  of  almost  any  contention  they  may 
make,  they  would  immediately  lose  their  activity  and  efficiency  as  re- 
sourceful damage  suit  lawyers.     *     *     « 

"The  time  is  probably  near  at  hand  when  the  companies  will  have 
to  give  more  attention  to  personnel  and  training  of  their  medical  exam- 
iners for,  with  the  existing  competition,  the  liberalizing  of  the  insurance 
contracts,  and  the  increasing  ingenuity  of  claimants,  more  attention 
will  have  to  be  given  to  the  validity  of  claims  presented.  *  *  * 
With  more  attention  paid  by  the  companies  to  the  selection  and  handling 
of  their  medical  advisors  over  the  country,  they  can  develop  a  corps 
of  officials  whose  ability  and  loyalty  can  be  counted  upon  in  the  protec- 
tion of  their  interests  and  the  prevention  of  imposition  on  the  part  of 
claimants,  attending  physicians  and  attorneys. 

"Competent  examiners  can  save  the  companies  money  on  almost 
every  claim  and,  under  both  accident  and  health  policies,  it  is  quite 
likely  that  medical  investigations  will  eventually  be  ordered  by  all 
companies  in  nearly  every  case  of  illness  or  accidental  injury  immedi- 
ately upon  receipt  of  notic,e.''^^ 

"It  is  one  of  the  conditions  of  the  sickness  insurance  policy  that 
indemnity  shall  only  be  paid  for  the  period  covered  by  regular  medical 
attendance,  and  here  we  encounter  a  very  difficult  problem;  the  doctor 
had  no  personal  relation  with  nor  interest  in  the  insurance  company, 
but  the  claimant  (his  patient)  is  one  of  the  community  in  which  the 
doctor  earns  his  income,  and  human  nature  asserting  itself,  the  doctor 
resolves  all  doubts  in  favor  of  his  patient,  and  prepares  his  certificate 
accordingly.  The  writer  would  not  have  it  understood  that  disregard 
of  the  company's  interest  is  the  rule  in  the  preparation  of  claim  blanks, 

•"W.  Edward  Magruder,  M.  D.,  Medical  examiner  and  adjuster  for  accident  in- 
siirance  companjes,  Baltimore,  in  chapter  on  "Medical  Examinations"  in  Dunham's 
Business  of  Insurance,  Vol.  II,  pp.  112-114  and  118. 


435 

but  it  is  ill  evidence  in  a  considerable  number  of  the  claims  handled. 
Some  companies  endeavor  to  overcome  this  difficulty  by  employing  a 
physician  other  than  the  claimant's  attendant  to  make  an  examination 
and  report  respecting  the  nature  of  the  sickness,  the  extent  and  duration 
of  the  disability,  and  the  probable  antecedent  physical  condition  of  the 
claimant.  But  here  again,  the  same  influences  are  to  some  extent 
present;  the  claimant  is  not  the  examiner's  patient,  but  the  examiner 
may  nevertheless  regard  such  relation  as  not  only  desirable  but  one  of 
the  possibilities  of  the  future :  the  claimant  may  become  a  regular  con- 
tributor to  the  doctor's  income,  while  the  insurance  company  pays  him 
a  single  fee  of  modest  proportions;  what  is  more  in  accord  with  human 
nature  than  that  the  examiner  will  0.  K.  the -certificate  of  the  regular 
medical  attendant? 

'^One  of  the  greatest  needs  of  sickness  insurance  as  a  business,  is  a 
corps  of  dependable  medical  examiners  covering  the  territory  in  which 
the  several  companies  operate.  The  common  employment  of  such  exam- 
iners would,  perhaps,  bring  sufficient  compensation  to  make  them  more 
or  less  indiipendent  of  local  support,  and  would  result  in  a  considerable 
saving  in  the  settlement  of  claims.""® 

The  development  of  the  health  and  accident  insurance  business  of 
well-managed  casualty  companies  into  a  safe  and  profitable  business 
need  not  be  described  nor  the  extent  of  the  profits  made  by  the  com- 
panies discussed.  It  is  sufficient  to  say  that  the  history  of  the  casualty 
companies  proves  that  it  is  possible  for  private  enterprise  operating 
upon  a  profit-seeking  basis  to  furnish  health  and  accident  insurance 
of  a  fairly  satisfactory  nature  at  rates  that  are  within  the  means  of 
persons  of  substantial  incomes. 

The  principal  defect  of  casualty  company  insurance  as  a  means  of 
meeting  the  needs  of  wage-earners  is  its  cost.  The  cost  of  casualty 
company  insurance  restricts  the  usefulness  of  this  insurance  among 
wage-earners  in  two  ways.  In  the  first  place  it  makes  the  purchase  of 
the  insurance  in  anything  like  an  adequate  amount  and  character  im- 
possible for  the  great  mass  of  wage-earners.  In  the  second  place,  it 
discourages  a  large  proportion  of  those  wage-earners  who  make  an 
attempt  to  carry  the  insurance  from  persevering  in  the  attempt.  The 
lapse  ratio  among  industrial  policy-holders  is  much  higher  than  the 
lapse  ratio  among  the  holders  of  commercial  policies. 

In  the  questionnaire  sent  to  the  casualty  companies  operating  in 
Illinois  the  Commission  asked  for  statements  of  the  "approximate  aver- 
age longevity  of  the  policies  issued  by  them  in  Illinois  and  the  "approxi- 
mate lapse  ratio"  in  Illinois*  Of  the  44  companies  which  returned  the 
questionnaire  24  gave  the  information  requested ;  some  of  the  remaining 
companies  stated  that  they  did  not  have  the  information  while  others 
gave  no  explanation  of  their  failure  to  comply  with  the  request  of  the 
Commission.  The  greatest  average  longevity  reported  was  5  years — 
reported  by  two  companies  which  sell  insurance  only  to  members  of 
certain  fraternal  orders ;  the  shortest  average  life  reported  was  3  months 

««Reinard  S.  Keelor,  M.  D.,  Liability  Underwriter  United  States  CasuaUy  Com- 
pany, etc.,  in  chapter  on  "Sickness  Insurance"  in  Dunham's  Btisiness  of  Insurance, 
Vol.  II,  p.  131. 


436 

— reported  by  three  companies  fgr  industrial  policies  sold  on  the  monthly 
premium  plan.  The  average  longevity  of  commercial  policies  for  all 
of  the  24  companies  would  probably  be  about  3  years  if  the  data  returned 
to  the  Commission  are  accurate;  while  the  average  life  of  the  industrial 
policies  for  those  companies  of  the  24  which  write  industrial  insurance 
would  probably  be  between  6  months  and  1  year. 

There  are  a  number  of  other  factors  to  be  considered  in  explaining 
the  lapse  ratios  of  health  and  accident  insurance  policies,  such  as  the 
failure  of  the  policyholder  to  appreciate  the  importance  of  his  insurance 
after  the  first  enthusiasm  kindled  by  the  agent  has  subsided,  the  re- 
moval of  the  policyholder  from  the  territory  of  the  agent  who  sold  him 
his  insurance  or  his  transfer  to  another  company,  but  there  is  little  doubt 
that  inability  to  continue  the  payment  of  premiums  is  one  of  the  im- 
portant causes  of  lapses  among  wage-earner  policyholders. 

Although  the  cost  is  the  principal  defect  in  casualty  company  health 
and  accident  insurance  as  a  means  of  protecting  wage-earners  against 
the  losses  which  result  from  sickness  and  accidents  there  are  other  im- 
portant defects  which  will  have  to  be  remedied  if  this  form  of  insurance 
is  to  be  modified  so  as  effectively  to  meet  the  needs  of  the  greater  num- 
ber of  wage-earners.  Mr.  Miles  M.  Dawson  has  stated  these  defects  as 
follows : 

"These  policies  (that  is,  the  health  and  accident  policies  of  the 
casualty  companies,  are  renewable  only  at  the  pleasure  of  the  company, 
which  means  that  if  the  insured  becomes  liable  to  frequent  disablement 
through  failure  of  health,  renewal  will  not  be  permitted. 

"The  company  has  power  to  vary  the  premium  rates  from  year  to 
year. 

"Indemnity  for  any  one  disability  is  limited  to  a  fixed  term ;  in  case 
of  sickness  to  twenty-six  weeks     *     *     *      >^67 

In  connection  with  the  first  defect  mentioned  by  Mr.  Dawson  the 
following  statement  from  Dr.  Eeinhard  S.  Keeler,  an  authority  who  like 
Mr.  Dawson  is  an  advocate  of  "continous  policies,^'  should  be  noted: 

"It  is  the  common  practice  when  making  settlement  of  a  claim  for 
sickness  due  to  a  disease  of  recurring  character,  or  a  disease  likely  to 
leave  a  troublesome  sequel,  to  insist  upon  the  elimination  of  liability  on 
the  part  of  the  company  for  sickness  resulting  directly  or  indirectly 
from  such  disease,  as  a  condition  precedent  to  the  continuation  of  the 
insurance.  Some  companies  accomplish  this  by  use  of  what  is  called  an 
eliminating  draft  in  payment  of  the  claim;  others  prepare  a  rider  or 
indorsement  and  attach  it  to  the  policy,  and  this  is,  doubtless,  the  better 
plan,  but  the  company  should  make  sure  that  it  is  signed  hy  the  policy- 
holder, and  that  it  is  actually  attached  to  the  policy.  Thus  the  scope 
of  the  insurance  may  in  course  of  time  be  considerably  narrowed  by  a 
process  of  elimination — something  that  could  not  be  done  under  con- 
tinuous policies  having  no  cancellation  clause.''^® 

"Miles  M.  Dawson,  The  Business  of  Life  Insurance,  1905,  pp.  244-245.  Mr. 
DawRon  does  not  confine  himself,  in  the  remarks  quoted,  to  the  needs  of  wage- 
earner.s  but  makes  his  criticism  f?eneral. 

«*  Reinard  S.  Keeler,  M.  D.,  Liability  Underwriter  United  States  Casualty  Com- 
pany, etc.,  In  chapter  on  "Sickness  Insurance"  in  Dunham's  jSw^iness  of  Insurance, 
Vol.  II,  p.  132. 


437 

It  is  perhaps  significant  that  the  only  progress  achieved  by  the 
casualty  companies  in  the  fourteen  years  since  Mr.  Dawson  made  the 
criticism  quoted  above  in  remedying  the  defects  noted  by  Mr.  Dawson 
is  in  the  lengthening  of  the  term  for  which  indemnity  for  loss  of  time 
resulting  from  sickness  is  paid  from  26  weeks  to  52  weeks  for  most 
commercial  policies. ^^  In  most  industrial  policies  the  term  is  still 
limited  to  6  or  8  months. 

PART   II.    INSUKANOB   BY    ASSESSMENT   ACCIDENT   AND   HEALTH    ASSOCIA- 
TIONS. 

(1)   Introductory. 

The  laws  of  the  State  of  Illinois  define  an  assessment  accident 
association  as  a  "corporation  organized  to  insure  against  the  contin- 
gency of  death  or  other  physical  disability  of  the  assured  thereunder 
resulting  from  accidental  injuries,  and  which  provides  for  the  payment 
of  policy  claims,  the  accumulation  of  reserve  or  emergency  funds,  and 
the  expenses  of  the  management  and  prosecution  of  the  business,  by  pay- 
ments to  be  made,  either  at  periods  named  in  the  contract  or  upon  assess- 
ment as  required  by  persons  holding  similar  contracts,  and  wherein  the 
insured^s  liability  to  contribute  to  the  payment  of  benefits  accrued  or  to 
accrue  is  not  limited  to  a  fixed  sum."^^ 

By  an  act  of  the  legislature  approved  June  4,  1909,  assessment 
accident  and  health  associations  are  authorized  to  amend  their  articles 
of  incorporation  so  as  to  include  among  their  corporate  powers  "the 
authority  to  insure  against  disability  resulting  from  sickness  or  disease, 
and  to  pay  to  the  beneficiaries  of  *  *  *  deceased  members  a  funeral 
benefit  which  shall  not  exceed  one  hundred  dollars  ($100)  in  event  of 
death  of  any  member/'^^ 

Assessment  accident  and  health  associations  have  no  capital  stock 
and  in  this  respect  they  differ  from  the  casualty  companies  with  which 
they  compete,  to  some  extent,  in  the  sale  of  health  and  accident  insur- 
ance. These  associations  are  in  form  mutual  companies  similar,  in 
some  respects  to  mutual  life  insurance  companies  and,  in  other  respects, 
to  mutual  fire  insurance  companies.  They  are  frequently  referred  to 
as  "mutual  accident  and  sick  benefit  associations."'^^  The  law  in  Illi- 
nois provides  that  the  associations  incorporated  in  the  State  "shall  be 
managed  by  not  less  than  five  directors,  trustees  or  managers,  a  majority 
of  whom  shall  be  residents  of  the  State  of  Illinois,  who  shall  be  selected 
from  and  by  the  members  *  *  *  f^^  svich.  period  not  exceeding 
three  years  as  may  be  provided  for  in  the  by-laws  and  may  be  eligible 
for  re-election."'^  The  law  further  provides  that  the  "board  of  directors, 
trustees  or  managers  shall  fix  the  amount  of  salary  or  per  cent  to  be 
paid  to  all  officers  and  managers  of  such  corporation"  and  that  they 
shall  not  "take  or  receive  any  of  the  money  or  funds  of  such  corporation 

«» It  is  assumed  without  investigation  that  Mr.  Dawson's  statement  of  the  time 
on  the  payment  of  sickness  indemnity  at  the  time  he  wrote  is  correct. 

'"^Insurance  Laws  of  the  State  of  Illinois,  1917,  compiled  by  the  Department  of 
Trade  and  Commerce  of  the  State  of  Illinois,  Insurance  Division,  Chapter  V,  p.  88. 

"Same,  pp.  95-96. 

"  See,  for  example,  the  Spectator  Company's  Accident  Insurance  Manuel  for 
1918,  p.  215,  and  the  Insurance  Year-Book  for  1916,  pp.  A365  to  A385  of  the  volume 
on  Life,  Casualty  and  Miscellaneous.' 

"/See  Insurance  Laws  of  the  State  of  Illinois,  1917,  p.  85. 


438 

in  excess  of  the  amount  of  salary  or  per  cent  so  fixed"  which  is  not  to 
be  changed  "during  the  term  for  which  such  officers  or  managers  are 
selected/^^^  || 

Assessment  accident  and  health  associations  differ  in  form  from  the  ' 
fraternal  societies  which  provide  sick  and  accident  benefits  in  the  absence 
of  the  lodge  system  with  ritualistic  work  and  ceremonies  and  the  repre- 
sentative form  of  government  which  characterize  the  latter/^  In  prac- 
tice the  management  of  the  assessment  association  is  less  democratic  than 
the  management  of  the  fraternal  societies,  resembling  in  this  respect 
the  management  of  the  mutual  life  insurance  companies. 

Little  has  been  written  concerning  the  history  of  these  associations. 
A  survey  of  the  "directory  of  mutual  accident  associations^^  and  the 
"directory  of  mutual  sick  benefit  associations"  in  the  Insurance  Year- 
Book  shows  that  three  associations  were  organized  prior  to  1880 — in 
1869,  1870  and  1872,  respectively — but  that  the  great  majority  have  been 
organized  since  1900. "^^  In  Illinois  only  three  of  the  20  assessment 
accident  and  health  associations  reported  by  Superintendent  of  Insurance 
Potts  as  operating  in  the  State  in  1916  were  organized  prior  to  1900; 
these  three  date  back,  respectively,  to  1885,  1890  and  1897."  Five  of 
the  Illinois  associations  and  one  of  the  "associations  of  other  states" 
included  in  the  20  associations  mentioned  were  organized  after  1910. 
The  principal  portion  of  the  Illinois  law  now  governing  the  assessment 
associations  was  enacted  in  1893.'^^  These  facts  indicate  that  the  assess- 
ment accident  association  plan  has  been  in  use  in  the  United  States  for 
at  least  half  a  century  and  that  it  still  is  a  plan  to  be  reckoned  with  in 
the  insurance  world.  Indeed  the  assessment  associations  have  been 
increasing  in  membership  fairly  steadily  and  rapidly  during  the  past 
two  decades. 

According  to  the  Insurance  Year-Book  for  1916,  sixty-one  mutual 
accident  associations  doing  business  in  the  United  States  had  725,399 
certificates  in  force  on  December  31,  1915,  and  116  mutual  sick  benefit 
associations  had  633,969  certificates  in  force  on  the  same  date.  During 
the  year  1915  the  two  types  of  associations  collected  from  their  members 
in  premiums  or  assessments  and  other  payments,  $6,862,167  and  $5,217,- 
375,  respectively,  and  returned  to  their  members  in  the  payment  of 
claims  $4,228,611  and  $2,726,503,  respectively.  The  business  of  the 
associations  increased  steadily,  with  the  exception  of  several  years  when 
decreases  from  the  business  of  the  preceding  year  were  experienced  by 
one  type  or  the  other,  from  1901  to  1915.  At  the  end  of  the  year  1901 
the  accident  associations  had  only  156,185  certificates  in  force  and  the 
mutual  sick  benefit  associations  only  153,907,  aggregating  about  23  per 
cent  of  the  aggregate  number  in  force  for  the  two  types  of  associations 
at  the  end  of  1915.^9 

"Ibid.,  p.  86. 

"Ibid.,  pp.  88-89  and  97. 

pp.  11^5^7 AZsl^''''^''''^  ^''''  ^^^^'  '^''^''"'^  ''''  "^'^^'  Casualty  and  Miscellaneous," 
'J  Insurance  Report  Illinois,  1917,  Part  III,  pp.  398-430 
8  Insurance  Laws  of  the  State  of  Illinois,  1917,  pp.   84  ff. 

or  not  al  o?tSf  assVn^ffnn^'^^l'^^^  ^?^  ^^^^  ^"  ^^^  Insurance  Yearbook  whether 

or  noi  ail  or  tne  associations  shown  in  it  are  strictlv  comnarnhip  witvi  t>io  TiiiTir>iQ 
assessment  accident  and  health  associations        '"-"'^^^^  comparable  with  the  niinois 


439 


(2)   Assessment  Accident  and  Health  Associations  in  Illinois. 

The  following  table  shows  the  important  statistical  details  of  the 
history  of  the  business  of  the  assessment  accident  associations  in  Illinois 
during  the  years  1913  to  1917,  inclusive.^^ 


Year. 


Certificates 
in  force 
Dec.  31. 


Received 

from  members 

for  indemnity 

and  expense 

purposes. 


Death, 

permanent 

disability,  sick 

and  accident 

claims  paid 

during  year. 


Certificates 

written 
during  year. 


Certificates  terminated 
during  the  year. 


By  death. 


By  lapse, 

surrender, 

etc. 


1913. 
1914 
1915 
1916 
1917 


158,530 
169, 766 
191, 150 
206,551 
228,030 


$1,421,292.10 
1, 557, 797. 91 
1, 782, 801.  50 
1,883,905.24 
2,067,324.05 


$1,094,847.81 
1, 263, 101. 90 
1,265,033.56 
1,032,312.37 


49,032 

670 

56,120 

684 

73,988 

712 

81,726 

750 

102,733 

35,  .526 
45, 802 
51,693 
59, 278 
t75,331 


*  Data  not   available. 

t  "Policies   terminated,"    presumably  for  all  causes. 

^  It  is  apparent  from  the  table  that  the  business  of  the  assessment 
associations  in  Illinois  has  been  increasing  steadily  and  rather  rapidly. 
The  number  of  certificates  in  force  at  the  end  of  1917  was  43.8  per 
cent  greater  than  the  number  of  certificates  in  force  at  the  end  of  1913. 
Information  as  to  the  distribution  of  the  business  between  health  insur- 
ance and  accident  insurance  is,  unfortunately,  not  available.  Many  of 
.the  contracts  written  by  the  associations  are  combination  contracts,  pro- 
viding both  kinds  of  insurance,  and  most  of  the  associations  which  re- 
turned the  questionnaire  sent  them  on  behalf  of  the  Commission  reported 
that  they  were  unable  to  supply  separate  data  for  the  two  kinds  of  in- 
surance. 

The  fourth  column  in  the  table  shows  the  total  amount  paid 'each 
3^ear  after  1913  by  all  the  associations  operating  in  the  State  for  death, 
permanent  disability,  sick  and  accident  claims.  A  very  large  propor- 
tion of  the  total  is  paid  for  sick  and  accident  claims;  a  minor  fraction 
for  death  claims  and  an  insignificant  percentage  for  permanent  dis- 
ability claims.  In  1916,  for  example,  $941,220.70,  or  approximately 
75  per  cent  of  the  total  amount  of  $1,265,033.56,  was  paid  for  sick  and 
accident  claims,  $319,812.86  was  paid  for  death  claims  and  only  $4,000 
for  permanent  disability  claims.^^ 

The  following  table  shows  the  assessment  accident  and  health  asso- 
ciations transacting  business  in  Illinois  in  1917  together  with  some  of 
the  more  important  statistical  details  of  the  business  done  by  them  in 
the  State  durinoj  the  vear.*- 

^  Compiled  from  the  Reports  of  the  Insurance  Superintendent  of  Illinois  for 
1914  to  1917,  inclusive,  and  the  Summary  of  the  Standing,  December  31,  1911,  of 
the  Assessm,ent  Life,  Accident,  or  Health  Associations  Transacting  Business  in  Illi- 
nois compiled  in  1918  by  Superintendent  of  Insurance  Potter. 

^^  Compiled  from  Insurance  Report  Illinois,  1917,  Part  III,  pp.  398-430. 

*-  Prom  the  Su7nmary  of  the  Standing,  December  31,  1917,  of  the  Assessvnent 
Life,  Accident,  or  Health  Associations  Transacting  Business  in  Illinois,  compiled, 
1918,  by  Superintendent  of  Insurance,  Fred  W.  Potter. 


440 


m 


Name  and  location  of  association. 


Policies 

written, 

restored, 

etc. 


Policies 
term- 
inated. 


Policies 

in  force 

end  of 

year. 


Received  from 

members 
during  year. 


Claims  paid 
during  year. 


ILLINOIS  ASSOCIATION. 

American  Indemnity  Co.,  Chicago.. 

Arcanian  Accident  Assn.,  Chicago. 

Bankers   Accident   Insurance   Co., 
Springfield 

Bankers  and  Merchants     Accident 
Assn.  of  Illinois,  Canton 

Bankers  Mutual  Accident  and 
Health  Co.,  Freeport 

Central  Business  Men's  Assn.,  Chi 
cago 

Clover  Leaf  Life  and  Accident  Insur- 
ance Co.,  Jacksonville 

Commercial  Health  and    Accident 
Co.,  Springfield 

Great  Northern  Casulaty  Co.,  Chi- 
cago   

Illinois   Commercial   Men's    Assn., 
Chicago  (accident  only) 

Illinois    Traveling    Men's    Health 
Assn.,  Chicago 

Insurance  Assn.   of  Railway  Em- 
ployees, Chicago 

Washington  Life  and  Accident  Assn. 
of  America,  Chicago 


Total. 


ASSOCLA.TIONS  OF  OTHER  STATES. 

Business  Men's  Accident  Assn.  of 

America,  Kansas  City,  Mo 

Fidelity  Health  and  Accident  Co., 

Benton  Harbor,  Mich.-. 

Fraternal  Protective  Assn.,  Boston, 

Mass 

Hoosier  Casualty  Co.,  Indianapolis, 

Ind 

Inter-State  Business  Men's  Accident 

Assn.,  Des  Moines,  Iowa 

Masonic  Mutual  Accident  Co., 

Springfield,  Mass 

Mutual  Benefit  Health  and  Accident 

Assn.,  Omaha,  Neb 

National    Accident    Society,    New 

York 

Woodmen  Accident  Co.,  Lincoln, 
Neb 


Total 

Aggregate. 


4,384 
20 

2,845 

711 

776 

8,821 

25,755 

3,416 

523 

16,607 

6,973 

670 

20, 291 


91,792 


3,520 
36 
95 

689 
1,980 
1,831 


640 
137 

4,325 

1,194 

121 

5,023 

19,145 

445 


15,332 
5,038 


15,120 


66,520 


617 
2,173 


10,941 


102,733 


2,434 
45 
51 

1,034 
2,170 

838 


292 

1,947 


8,811 


4,375 
413 

2,643 

2,251 

942 

12,917 

9,376 

2,971 

523 

118,977 

38,551 

670 

13, 914 


208,523 


5,446 

15 

198 

512 

2,984 

2,413 


756 
7,183 


19,507 


75,331 


228,030 


$        4,339.88 
4, 156. 45 

48,904.80 

32,483.69 

18,892.87 

156,772.75 

68,328.13 

12,653.66 

2,902.63 

1,006,800.25 

426,530.25 

1,340.00 

93,241.60 


$1,877,346.96 


$59,840.36 

55.30 

2,121.55 

8,768.18 

34,902.86 

21,684.46 


6,876.99 
55,727.39 


$189,977.09 


$2,067,324.05 


$       387. 66 
719. 20 

9, 170. 72 
10,929.27 

1,936.66 

63,017.15 

16,572.84 

V  627. 98 


523,769.11 
294, 215.  54 


23,980.26 


$945,326.39 


$26, 558. 75. 

512.25 

1,113.46 

4,255.57 

13,470.72 

10,664.05 


1,045.88 
29,365.30 


$86,985.98 


$1,032,312.37 


It  is  appareut  from  the  large  proportion  of  the  total  membership 
of  the  assessment  accident  and  health  associations  in  Illinois  which  is 
found  in  the  two  associations  of  traveling  men  that  only  a  minor  frac- 
tion of  the  membership  is  composed  of  wage-earners  as  distinguished 
from  salaried  persons,  business  and  professional  men.  The  three  asso- 
ciations whicli  employ  the  name  "business  men's,  association"  use  the 
term  correctly,  for  one  reports  that  it  confines  its  business  "strictly  to 
business  and  professional  men,"  a  second,  that  not  more  than  10  per 
cent  of  its  members  are  wage-earners,  and  the  third,  that  "25  per  cent 
or  more"  arc  wage-earners.  One  association  reports  that  its  members 
are  "nearly  all  farmers  and  residents  of  small  towns  and  villages  in 
northern  Illinois."  Several  associations,  as  their  names  indicate,  includ- 
ing the  Fraternal  Protective  Association,  confine  their  membership  to 


441 

the  members  of  certain  fraternal  societies  and  the  proportion  of  wage- 
earners  among  their  policyholders  will  therefore  depend  somewhat  upon 
the  character  of  the  societies  from  which  they  are  drawn.  One  of  these 
associations  states  that  78  per  cent  of  its  members  are  wage-earners. 
Two  other  associations,  not  mentioned  above,  of  the  eleven  which  re- 
turned replies  to  the  questionnaire  of  the  Commission,  stated  that  prac- 
tically all  of  their  policyholders  were  wage-earners.  All  things  consid- 
ered, it  seems  reasonable  to  conclude  that  no  more  than  40,000  wage- 
earners  carried  health  and  accident  insurance  with  assessment  associa- 
tions in  Illinois  at  the  close  of  the  year  1917. 

(3)  Policy  Contracts  Used  hy  the  Assessment  Accident  and  Health 
Associations. 

The  limits  of  time  and  space  do  not  permit  a  detailed  description 
of  the  contracts  used  by  the  associations  in  Illinois,  but  it  may  be  said 
that  in  general  they  resemble  the  contracts  of  the  casualty  companies 
in  the  benefits  provided.  Insurance  is  written  by  some  associations 
against  loss  of  time  from  sickness  or  accident  injuries,  loss  of  sight 
from  accident  or  disease,  and  loss  of  life  or  limb  from  accident,  with 
provision  for  surgical,  hospital,  quarantine  and  identification  benefits 
similar  to  those  found  in  the  policies  of  casualty  companies.  Some  of 
the  policies  written  by  the  associations  provide  for  death  benefits  or 
funeral  benefits  for  loss  of  life  by  sickness  as  well  as  for  loss  of  life  by 
accident.  Individual  policies  may  contain  part  or  all  of  the  benefits 
mentioned  above  and  health  and  accident  policies  may  be  written  sepa- 
rately or  in  combination.  Most  of  the  policies  contain  the  standard 
provisions  prescribed  by  the  Standard  Provisions  Law  of  1915.^^ 

The  payments  made  to  the  associations  by  their  members  usually 
include  a  membership  or  policy  fee  and  quarterly  or  annual  payments 
of  specified  amounts.  The  membership  fee  varies,  in  the  contracts 
which  have  been  submitted  to  the  Commission,  from  $2  to  $5.  The 
quarterly  or  annual  payments  are  divided  into  two  parts,  often  separately 
stated,  of  which  one  is  to  cover  expense  and  the  other  the  pro  rata  cost 
of  the  benefits  paid  on  the  claims.  Although  the  associations  frequently 
state  the  amounts  of  the  periodical  contributions  in  definite  terms,  they 
possess  the  power,  under  the  assessment  association  law,^*  to  call  upon 
the  policyholders  for  further  contributions  if  the  latter  are  necessary 
to  meet  the  liabilities  of  the  association.  In  some  associations  the  maxi- 
mum amount  of  each  contribution  or  assessment  is  fixed,  but  the  fre- 
quency of  payment  left  to  be  determined  by  the  board  of  directors  in 
accordance  with  the  needs  of  the  association.  In  other  associations,  as, 
for  example,  in  one  of  the  business  men's  associations,  the  cost  of  the 
insurance  is  paid  by  the  member  in  a  single  annual  premium,  the 
amount  of  which  is  definitely  stated  in  the  policies  and  advertising 
literature  used  by  the  association. 

One  association  which  replied  to  the  questionnaire  of  the  Commis- 
sion writes  a  weekly  payment  policy  which  is  especially  designed  to 
appeal  to  wage-earners.     This  policy  provides  a  death  benefit  payable 

^Insurance  Laws  of  the  State  of  Illinois,  1917,  pp.  125-134. 
8*  Same,  p.  88. 


442 

whether  or  not  death  results  from  accident,  a  weekly  indemnity  for  loss  of 
time  from  disability  caused  by  accident  or  disease,  and  specific  additional 
indemnities  for  loss  of  hand,  foot,  sight  or  hearing.  Women  are  prom- 
ised a  maternity  benefit  equal  to  the  sickness  indemnity  for  one  week. 
Information  concerning  the  amounts  of  the  benefits  and  their  cost  was 
not  furnished. 

(4)   Cost  of  Assessment  Association  Health  and  Accident  Insurance. 

The  assessment  associations  claim  that  they  provide  insurance  at 
considerably  lower  rates  than  do  the  casualty  companies.  The  Com- 
mission has  not  had  the  time  necessary  conclusively  to  verify  or  disprove 
this  claim,  which  is  a  somewhat  difficult  thing  to  do  in  view  of  certain 
differences  in  the  type  of  protection  provided.  Eeference  to  the  table 
on  page  —  shows  that  during  the  years  1914  to  1917,  inclusive,  the 
associations  returned  to  their  members  approximately  two-thirds  of  the 
amounts  collected  from  them  and  in  1917  approximately  half.  Eefer- 
ence to  the  table  on  a  preceding  page,  however,  will  show  that  the  pro- 
portion for  the  associations  as  a  group  does  not  hold  true  of  all  the 
individual  associations. 

The  association  mentioned  above  as  specializing  in  weekly-premium 
insurance  for  wage-earners  collected  about  four  times  as  much  from 
its  members  in  1917  as  it  returned  to  them  in  1917.  During  the  four 
years  1913  to  1916,  inclusive,  this  association  collected  from  its  mem- 
bers and  applicants,  as  shown  by  the  annual  reports  of  the  Superintend- 
ent of  Insurance,  the  sum  of  $134,9.21.53,  net,  and  returned  to  its 
members  in  death,  sick  and  accident  benefits  the  sum  of  $41,075.43,  or 
30.4  per  cent  of  the  amount  collected.  During  the  same  period  it  paid 
commissions  and  fees  to  its  agents  amounting  to  $51,968.86,  or  126.5 
per  cent  of  the  amount  paid*  to  its  members,  besides  salaries  of  man- 
agers or  agents  amounting  to  $6,627.26.  This  high  ratio  of  expenses 
to  claims  paid  may  be  partly  due  to  the  fact  that  the  association  is  young, 
but  it  is  largely  the  result  of  an  agency  and  ^weekly  collection  system 
which  is  necessarily  costly.  Another  association  which  has  been  oper- 
ating in  Illinois  for  more  than  20  years  and  which  writes  industrial 
health  and  accident  insurance,  collected  from  its  members  and  appli- 
cants during  the  j^ears  1913  to  1916,  inclusive,  the  amount  of  $225,- 
859.65,  net,  and  returned  to  its  members  $53,129.81,  or  23.5  per  cent 
of  the  amount  collected. 

(5)    Value  of  Assessment  Insurance. 

It  is  apparent  from  the  foregoing  discussion  that  it  is  possible  to 
persuade  a  limited  number  of  wage-earners  to  buy  assessment  accident 
and  health  insurance  even  though  collectively  they  receive  in  benefits 
considerably  less  than  half,  sometimes  less  than  a  third,  of  the  amount 
they  contribute  to  the  associations.  But  it  is  also  obvious  that  insurance 
which  is  so  costly  that  a  payment  of  from  two  to  three  dollars  is  required 
to  insure  a  cash  benefit  of  one  dollar  cannot  be  of  material  assistance 
in  solving  the  problem  of  health  insurance  for  wage-earners. 


443 


SPECIAL  REPORT  VII.     FRATERNAL  INSURANCE. 


I.  Introductory. 

Among  the  voluntary  insurance  institutions  which  serve  the  wage- 
earners  of  Illinois  the  fraternal  orders  stand  first  in  the  amount,  the 
variety  and  the  general  efi'ectiveness — in  spite  of  some  defects — of  the 
insurance  provided  members  of  this  class.  It  is  impossible  to  say 
definitely  how  many  wage-earners  in  the  State  are  insured  in  these 
orders  for  the  available  records  of  the  orders  do  not  reveal  this  informa- 
tion and  it  is  availiable  nowhere  else.  According  to  the  report  of  the 
Superintendent  of  Insurance  for  1918,  the  "fraternal  beneficiary  societies 
authorized  to  do  business  in  the  State  of  Ilinois^'  had  an  aggregate  mem- 
bership in  the  State  on  December  31,  1917,  of  1,043,469  persons.^  All 
or  practically  all  of  the  members  included  caried  life  insurance  in  the 
orders  of  which  they  were  members.  Many  were  insured  in  the  orders 
against  sickness  and  accidental  injuries.  The  "fraternal  beneficiary 
societies"  covered  in  Superintendents  Potter's  report  include  only  those 
societies  which  provide  life  insurance.  There  are  a  number  of  other 
fraternal  orders  operating  in  Illinois  which  do  not  provide  life  insurance 
but  which  do  furnish  their  members  or  some  of  their  members  with  sick 
benefits  in  return  for  the  payment  of  dues  designed  to  cover  the  cost  of 
the  benefits.  Many  fraternal  orders,  of  course,  give  charitable  donations 
through  the  local  lodges  or  otherwise  to  members  who  are  in  distress ;  but 
charity  is  not  insurance,  however  commendable  it  may  be  in  purpose  and 
results,  and  it  will  occordingly  be  omitted  from  the  discussion  in  this 
study.  Some  persons  are  members  of  two  or  more  fraternal  beneficiary 
societies  and  are  thus  counted  twice  or  more  than  twice  in  Superin- 
tendent Potter's  report.  Allowance  must  be  made  for  this  double  count- 
ing in  using  the  report  as  a  basis  for  estimating  the  number  of  wage- 
earners  and  members  of  wage-earning  families  in  Ilinois  who  are  insured 
in  the  fraternal  orders.  On  the  other  hand  account  must  be  taken  of 
persons  who  are  insured  for  "sick  benefits"  in  those  fraternal  orders 
which  are  not  included  in  the  Superintendent's  report.  Finally,  an 
estimate  must  be  made  of  the  proportion  of  the  total  number  of  persons 
insured  in  the  fraternal  orders  who  are  members  of  the  wage-earning 
class.  After  giving  careful  consideration  to  all  the  elements  mentioned, 
the  conclusion  has  been  reached  that  it  is  safe  to  assume  that  the  fra- 
ternal orders  in  Ilinois  provide  insurance  of  one  or  more  kinds  for  at 
least  750,000  persons — men,  women  and  children — of  the  wage-earning 
class. 

The  fraternal  orders  vary  greatly  in  the  number  and  character  of 
the  insurance  "benefits"  which  they  provide  for  their  members.  An 
order  may  offer — subject  to  such  legal  restrictions  as  may  be  in  force 

^Insurance  Report  Illinois,  1918,  Part  II,  pp.  67-71. 


444 

in  the  State  in  which  it  is  chartered  or  licensed  to  do  business — one  or 
more  of  the  following  indemnities:  death  benefits  (life  insurance), 
funeral  benefits,  'Svliole  family  protection^'  (juvenile  life  insurance), 
old  age  and  disability  benefits,  sick  and  accident  benefits,  maternity 
benefits. 

The  fraternal  orders  have  had  a  long  and  varied  experience  with 
some  of  the  forms  of  insurance  mentioned  and  the  results  of  this  ex- 
perience should  be  of  great  value  in  the  consideration  of  any  detailed 
plans  which  may  be  proposed  for  the  solution  of  the  problem  of  health 
insurance  for  wage-earners.  The  orders  are  organized  on  a  democratic 
and  cooperative  basis;  their  activities  in  providing  their  members  with 
insurance  thus  constitute  a  "great  experiment  in  the  possibilities  of  a 
democratic,  cooperative,  non-profit-seeking  organization  of  the  business 
of  personal  insurance.  These  facts  and  the  fact  that  the  orders  are  now 
providing  some  750,000  persons,  more  or  less,  in  the  wage-earning  class 
in  Illinois  with  one  or  more  forms  of  personal  insurance  warrant,  the 
Commission  believes,  the  detailed  study  which  has  been  made  of  fraternal 
insurance. 

The  information  upon  which  this  study  is  based  was  gathered  by 
personal  interview,  correspondence  and  investigation  of  the  records  of 
the  Superintendent  of  Insurance  and  the  literature  of  fraternal  insur- 
ance. 

One  or  more  officers  of  the  grand  lodges  of  45  of  the  62  fraternal 
life  insurance  orders  which  had  their  headquarters  in  Chicago  or  else- 
where in  Illinois  on  December  31,  1917,  were  interviewed  by  a  repre- 
sentative of  the  Commission.  The  Chicago  or  Illinois  representatives 
of  a  number  of  life  insurance  orders  whose  grand  lodges  are  located 
outside  of  Illinois  and  the  Chicago  or  State  officers  or  representatives 
of  a  number  of  orders  which  furnish  sick  benefits  or  sick  and  accident 
benefits  only  were  also  interviewed. 

Questionnaires  calling  for  detailed  information  concerning  the 
character  and  amount  of  the  death  benefits  or  life  insurance,  the  sick 
benefits  and  other  benefits  furnished  by  the  grand  lodge  or  the  sub- 
ordinate lodges  in  Illinois  were  sent  to  the  officers  of  the  grand  lodge 
of  each  of  the  149  fraternal  life  insurance  orders  which  were  operating 
in  the  State  at  the  close  of  the  year  1917.  Satisfactory  returns  were 
received  from  125  of  the  149  societies  and  the  information  for  one 
society  was  obtained  from  the  local  representative  in  Chicago.  The  126 
societies  thus  accounted  for  represented  on  December  31,1917,  95  per 
cent  of  the  Illinois  membership  of  the  fraternal  life  insurance  orders  in 
Ilinois.  Of  the  23  societies  which  failed  to  return  the  information  re- 
quested by  the  Commission,  six  were  small  Illinois  societies  with  an 
aggregate  membership  in  Illinois  on  December  31,  1917,  of  11,011  and 
17  were  small  out-of-State  societies  with  an  aggregate  membership  in 
Illinois,  on  the  date  named,  of  46,003.  Questionnaries  similar  to  those 
sent  to  the  fraternal  life  insurance  orders  were  sent  to  a  number  of 
fraternal  socieites  which  furnish  sick  benefits  but  do  not  furnish  life 
insurance  and  whose  officers  had  not  been  interviewed  personally  by 
representatives  of  the  Commission. 

Finally  questionnaires  to  the  number  of  4,900  were  sent,  with  the 
cooperation  of  the  grand  lodges,  to  the  local  lodges  of  a  number  of  orders 


445 

in  which  the  provision  of  sick  benefits  is  left  to  the  local  lodges.  The 
Commission  received  1,871  replies,  and,  though  it  regrets  that  the  number 
is  not  greater,  it  feels  that  the  replies  received  are  fairly  representative 
of  the  conditions  under  which  sick  benefits  and  other  forms  of  insurance 
are  provided  in  Illinois  by  the  local  lodges  of  the  fraternal  orders 
concerned. 

II.  Fraternal  Life  Insurance. 

(1)  History. — Historically,  fraternal  life  insurance  seems  to  have 
appeared  in  the  United  States  largely  as  the  expression  of  a  protest 
against  the  maintenance  of  legal  reserves  by  the  "old-line"  life  insur- 
ance companies  and  the  unfair  treatment  given  withdrawing  policy- 
holders by  these  companies  before  the  non-forfeiture  laws,  first  enacted 
in  Massachusetts  in  1861,  became  general.^  Opposition  to  the  main- 
entance  of  the  reserve  was  based  partly  upon  ignorance  of  the  functions 
of  the  reserve  and  partly  upon  the  practice  then  follow^ed  by  many  com- 
panies of  returning  no  portion  of  the  reserve  pertaining  to  his  policy  to 
the  policyholder  who  was  compelled  to  lapse  his  policy.  A  reserve  in 
life  insurance,  the  promoters  and  friends  of  fraternal  insurance  asserted, 
was  as  unnecessary  as  ''the  fifth  wheel  of  a  wagon."^  Originally  the 
plan  of  the  fraternal  societies  was  to  collect  "the  amount  of  a  claim 

*  *  *  after  the  death  of  the  insured  by  levying  an  assessment  upon 
the  living^  members."* 

"There  is  no  doubt  that  this  practice  of  post-mortem  assessments 

*  *  *  came  into  use  because  of  men's  unwillingness  to  part  with 
their  money  until  it  is  needed  and  as  a  result  of  suspicion  of  the  accumu- 
lation of  money  in  the  hands  of  the  regular  companies.  This  sentiment 
caused  the  adoption  of  the  following  motto :  The  best  place  for  a 
dollar — (that  is,  until  required) — is  the  pocket  of  the  man  who  made 
it.  The  idea  was  to  call  in  money  as  needed  and  not  a  moment  before ; 
and  the  assessments  were  originally  a  certain  sum  upon  each  living  mem- 
ber at  the  death  of  a  member.  The  benefit  paid  at  the  death  of  a  mem- 
ber was  collected  in  this  way  by  one  assessment."^ 

The  first  fraternal  order  to  undertake  the  provision  of  life  insur- 
ance in  the  United  States,  according  to  most  historians  of  fraternal 
insurance,^  was  the  Ancient  Order  United  Workmen.  This  order  was 
organized  at  Meadville,  Pennsylvania,  October  27,  1868,  by  John  J. 
Upchurch. 

"The  object  and  purposes  of  the  Order  when  founded  were  first 
to  bring  employer  and  employees  together  in  a  common  fraternal  home. 
Its  members  w^ere  limited  to  mechanics  and  their  helpers,  artists  and 
their  assistants  of  the  various  branches.  Protection  of  the  home  by 
way  of  insurance  was  provided  for  after  the  Order  had  a  membership  of 
one  thousand,  but  the  insurance  feature  was  secondary .^^^ 

^  Miles  M.  Dawson,  Assessment  Life  Insurance,  pp.  9-14  ;  Solomon  S.  Huebner, 
Life  Insurance,  p.  231. 

'.  *■  Quotations  from  Miles  M.  Dawson,  work  cited,  pp.  3,  4. 

**  Miles  M.  Dawson,  work  cited,  p.   3. 

"  Sec  Miles  M.  Dawson.  Assessment  Life  Insurance,  p.  23  ;  A.  R.  Talbot,  Fra- 
ternal Tjife  Insurance  in  Dunham,  Business  of  Insurance,  Vol.   1,  pp.   438-439. 

""'The  Loyal  Workm,an,"  Official  Org'an  of  the  Ancient  Order  United  Workmen 
Dcs  Moines.  Iowa,  Jubilee  Number,  October,  1918,  p.  2. 


446 

For  the  purposes  of  the  present  study  the  details  of  the  history  of 
fraternal  life  insurance  in  the  United  States  need  not  be  presented. 
Mention  will  be  made,  however,  of  certain  important  influences  which 
have  affected  the  development  of  this  form  of  insurance  in  the  United 
States. 

The  success  of  the  Ancient  Order  United  Workmen  during  the 
years  following  its  organization  in  1868  "caused  a  large  number  of 
similar  organizations  to  spring  up,  first  in  Pennsylvania  and  then 
wherever  the  new  and  flourishing  order  penetrated.^^^  The  growth  of 
the  new  form  of  life  insurance  was  due  largely,  as  has  already  been 
explained,  to  popular  opposition  to  the  maintenance  of  legal  reserves 
and  the  retention  of  funds  contributed  by  withdrawing  policyholders  or 
dividends  on  these  funds  by  the  "old-line"  life  insurance  companies. 
The  failure  of  71  "old-line"  companies  during  the  decade  from  1868 
to  1887,  inclusive,^  gave  an  added  impetus  to  the  fraternal  insurance 
movement.  The  "startling  disclosures"  which  were  made  "as  to  the 
methods  followed  by  some  of  the  most  prominent  among  them"  showed 
that  "extravagance  and  mismanagement  ran  riot;  self-interest  dominated 
official  conduct  and  utter  recklessness  characterized  the  investment  of 
funds."i« 

Under  the  circumstances  it  w^as  natural,  if  unfortunate,  that  the 
battle  cry  of  "Keep,  your  reserve  in  your  own  pocket"^^  should  control 
the  insurance  plans  of  the  new  societies  and  result  in  the  establishment 
of  fraternal  insurance  upon  a  high  unscientific  basis.  Various  plans 
for  collecting  funds  were  adopted,  including  the  assessment  of  all  mem- 
bers alike,  regardless  of  age,  and  the  assessment  of  members  according 
to  age  at  entry.  Many  of  the  societies  failed;  others  survived  only 
because  of  the  strong  fraternal  spirit  which  animated  them  or  because 
of  other  unusually  favorable  circumstances.  The  experience  of  the 
fraternal  societies  in  their  attempt  to  provide  cheap  insurance  by  dis- 
regarding the  fundamental  principles  of  actuarial  science  has  been 
described  as  follows  by  Dr.  B.  H.  Meyer : 

"It  would  be  a  thankless  task  to  rehearse  the  long  tale  of  failures 
among  fraternal  societies.  Besides,  old  line  companies  and  other  de- 
partments of  the  mercantile  world  have  had  their  epidemics  of  financial 
ruin.  Yet,  excepting  paper  money  crazes,  history  probably  affords  no 
parallel  to  the  blind  and  persistent  adhesion  which  so  many  people  in 
all  parts  of  the  United  States  have  shown  to  hopelessly  unsound  schemes 
of  fraternal  insurance.  An  examination  of  many  such  schemes  leaves 
upon  one  the  impression  that  their  promoters  thought  of  certain  sums  of 
money  to  be  paid  as  benefits  under  certain  conditions  on  the  one  hand, 
and  of  certain  contributions  which  it  might  be  convenient  to  make  on 
the  other,  without  apparently  reflecting  upon  a  possible  casual  connec- 
tion between  the  two.  The  history  of  such  organizations  is  quite  gener- 
ally the  same.  A  rapid  increase  in  the  membership,  possibly  also  a 
simultaneous  reduction  in  the  average  age;  a  gradual  increase  in  the 

»  Miles  M.  Dawson.  Assessment  Life  Insurance,  p.  23 

•Lester  W.  Zartman,  History  of  Life  Insurance  in  the  United   States  in  Yale 
Readings  in  Insurance,  Personal  Insurance,  p.  89. 

„  ,."\^^  ^^S*^^^' ,^^^^  Insurance  by  Fraternal  Orders,  Annals  American  Academy 
Pohtical  and  Social  Science,  Vol.  24,   (1904),  p.  478. 
"Abb  Landis,  work  cited,  p.  479. 


447 

death  rate,  accompanied  by  increasing  difficulty  in  securing  new  mem- 
bers; an  increase  in  assessments  or  rates  and  loss  of  members,  or  an 
attempt  to  slide  along  without  raising  assessments;  and  finally,  finan- 
cial failure.  That  some  fraternal  societies  are  thoroughly  sound,  finan- 
cially, and  that  others  have  successfully  advanced  rates  and  maintained 
the  integrity  of  their  organizations  does  not  affect  this  general  state- 
ment. On  the  other  hand,  the  very  fact  that  an  increase  in  contri- 
butions was  found  necessary  in  various  societies  is  prima  facie  evidence 
that  the  original  scheme  was  financially  unsound."^^ 

Fortunately  for  the  fraternal  orders,  the  original  lack  of  an  actu- 
arily  sound,  basis  for  the  insurance  which  they  offered  the  public  is  not 
a  defect  which  was  inherent  in  the  fraternal  plan.  The  leaders  of  many 
of  the  orders  have  recognized  the  necessity  for  the  aid  of  actuarial 
science  in  the  computation  of  rates  and  for  the  establishment  of  ade- 
quate reserves  and  in  a  considerable  number  of  cases  have  persuaded  the 
rank  and  file  of  the  membership  to  adopt  "adequate  rates.'^  In  other 
cases  the  societies  are  struggling  toward  this  ideal  which  was  so  abhor- 
rent to  the  original  and  many  later  promoters  of  fraternal  insurance. 
To  encourage  or  to  compel  progress  in  this  direction  the  so-called 
Mobile  and  New  York  Conference  bills  have  already  been  enacted  into 
law  in  a  number  of  states,  and  presented  to  the  legislatures  of  other 
states  for  consideration.  Details  of  these  model  bills  will  be  discussed 
later  in  this  study. 

"In  trying  to  reorganize  their  scale  of  rates  the  societies  are  encoun- 
tering much  opposition  from  their  members  and  are  experiencing  much 
difficulty  in  educating  them  to  an  understanding  of  the  situation.  The 
problem  involved  is  a  serious  one  since  many  of  the  societies  have  been 
in  existence  for  many  years  and,  owing  to  their  inadequate  rates  during 
the  whole  of  their  existence,  are  now  obliged  to  increase  their  rates 
enormously  in  order  to  meet  current  claims.  In  other  words,  their 
problem  is  to  find  some  way  of  meeting  the  situation  which  has  grown 
out  of  the  accumulating  deficits  of  past  years.  And  in  trying  to  solve 
this  problem  the  societies  must  contend  with  the  conflicting  interests 
of  different  classes  of  members.  The  older  members  naturally  favor  the 
retention  of  the  old  methods,  since  the  raising  of  rates  at  the  older  ages 
to  an  adequate  basis  would,  in  many  instances,  mean  an  unbearable 
burden.  The  younger  members,  on  the  other  hand,  feel  that  they  should 
not  be  asked  to  contribute  for  the  benefit  of  the  older  members,  and 
are  therefore  not  so  inclined  to  oppose  a  more  equitable  rate  adjustment. 
In  their  attempts  to  reform  their  rating  systems  the  societies  have  in 
most  instances  tried  to  compromise  between  these  two  classes  of  mem- 
bers, i.  e.  when  deficiencies  made  it  necessary  rates  were  increased  but 
the  increase  was  greater  at  the  older  ages  than  at  the  younger  ones. 
Many  feel  that,  the  only  solution  available  ig  *  *  *  ^^q  g^  regulate 
the  inequality  between  the  groups  that  additions  to  the  young  member- 
ship can  be  kept  up  until  such  time  as  the  rates  can  step  by  step  be 
finally  raised  to  an  adequate  basis.'  ^'^^ 

^^B.  H.  Meyer,  Fraternal  Insurance  in  the  United  States,  Annals  American 
Academy  Political  and  Social  Science,  Vol.  17,   (1901),  pp.  261-263. 

"Solomon  S.  Huebner,  Life  Insurance,  p.  269.  Dr.  Huebner's  quotation  is  from 
Walter  S.  Nichols,  Yale  Readings  in  Insurance,  Personal  Insurance,  p.  378. 


448 


The  following  table'*  shows  the  growth  of  fraternal  life  insurance 
in  the  United  States  in  recent  years. 


Year. 


Number 

of 
societies. 


Insurance 

written  during 

the  year. 


1901. 
1902. 
1903. 
1904. 
1905. 
1906. 
1907. 
1908. 
1909. 
1910. 
1911. 
1912. 
1913. 
1914. 
1915. 
1916. 
1917. 


489 
580 
509 
575 
570 
590 
543 
547 
645 
497 
396 
397 
509 
498 
472 
523 


Insurance  in  force  at  end  of  year. 


Number  of 
certificates. 


Amount. 


S    799, 

1,278, 
1,313, 
1,015, 
1,026, 
1,111, 
1,212, 
1,120, 
1,203, 
1,331, 
1,200, 
1,023, 
1,065, 
1,079, 

922, 
1,115, 

822, 


626,678 
267,000 
432,520 
889,021 
308, 429 
906,048 
382,432 
569, 228 
403,691 
552, 713 
633, 063 
726, 087 
071, 108 
569, 596 
890,579 
784,564 
041,734 


4,518,955 
4,947,370 
5,644,619 
6,054,296 
6, 118, 938 
6,890,564 
7,282,416 
7,887,365 
7,909,626 
8,558,093 
10, 122, 169 
9,963,019 
8,058,317 
7,868,554 
7,695,944 
8,674,996 
7,456,551 


$5,656, 
6,115, 
6,606, 
7, 273, 
8, 150, 
8, 136, 
8, 079, 
8,438, 
8,920, 
9,562, 
9,839, 
9,472, 
9,622, 
9,171, 
8,694, 
9, 162, 
9, 129, 


453, 465 
735,000 
608, 321 
069,328 
350, 736 
201,919 
743, 281 
204,968 
716,227 
511,910 
909,282 
232, 473 
276, 590 
284,227 
449,483 
111,616 
974,447 


With  the  number  of  certificates  outstanding  in  1917  reduced  some- 
what as  an  effect  of  the  war,  the  number  of  certificates  approached  the 
number  of  policies  outstanding  against  the  "old-line"  life  insurance 
companies,  for  the  number  of  such  policies  was  recently  estimated  at 
7,800,000.15 

(2)  Fraternal  life  insurance  in  Illinois. — Illinois  stands  first  among 
the  states  in  the  number  of  fraternal  life  insurance  certificates  in  force 
and  has  the  distinction  of  being  the  home  of  a  number  of  the  largest 
fraternal  insurance  orders  in  the  country,  including  the  Modern  Wood- 
men of  America,  which  is  the  largest  of  all.  The  following  table  shows 
the  Illinois  membership  of  the  fraternal  life  insurance  orders  each  year 
during  the  five-year  period  1913-3  917,  inclusive,  together  with  other 
important  details  of  the  business  done  in  Illinois  by  these  orders.'^ 


Year  ending  Dec.  31. 


Illinois  business. 


Number 

of  members 

Dec.  31. 


Amount  of 
indemnity  in 
force  Dec.  31. 


Received  from 

members  in 

Illinois  for 

mortuary 

indemnity  and 

expense 

purposes. 


Amount  of 
[claims  paid  in 
I        Illinois. 


1913 
1914 
1915 
1916 
1917 


983,538 

992,346 

1,010,350 

1,017,183 

1,043,469 


$1,153,283,100 
1,153,255,974 
1,158,546,228 
1,143,550,832 
1,164,471,525 


(*) 
(*) 
(*) 
$14,858,409 
15,298,170 


(*) 
(*) 
(*) 
$13, 121, 251 
14,086,344 


•  Data  not  shown  in  the  Reports  of  the  Insurance  Superintendent  until  1916. 

"From  the  Insurance  Yearbook  for  1916,  p.  376. 

'•"' News  Items  in  The  Spectator,  December  12,  1918. 

"Compiled  from  the  Reports  of  the  Superintendent  of  Insurance  of  Illinois, 


449 

The  fraternal  life  insurance  orders  which  operate  in  Illinois  are  a 
variety  of  types.  A  large  number  are  open  to  all  white  persons  of  "good 
moral  character"  who  are  not  engaged  in  prohibited  occupations  and 
who  are  not  outside  the  age  limits  specified  for  initiation  as  members. 

The  qualifications  for  membership  in  other  societies  may  involve 
race,  nationality  or  knowledge  of  a  foreign  language,  sex,  religious 
affiliations,  or  occupation.  The  Poles,  Bohemians,  Croatians,  Jews, 
Swedes,  Italians,  Germans,  and  Negroes  have  two  or  more  fraternal 
societies  each,  and  each  of  several  other  races  are  represented  in  Illinois 
bv  at  least  one  fraternal  life  insurance  order.  Adherents  of  the  Roman 
Catholic  faith  have  their  choice  of  a  number  of  orders,  some  of  which 
have  race  qualifications  and  some  of  which  do  not.  Lutherans  have  a 
similar  but  more  restricted  choice.  Persons  following  especially  hazard- 
ous occupations  are  commonly  excluded  from  membership,  and  persons 
employed  in  saloons  or  in  other  enterprises  connected  with  the  traffic  in 
intoxicating  liquors  are  frequently  excluded.  A  few  orders  restrict 
their  membership  entirely  or  largely  to  persons  engaged  in  a  single 
occupation  or  in  a  group  of  closely  related  occupations.  There  are 
several  societies  of  this  type  among  railway  employees  and  several 
among  commercial  travelers.  Many  orders  admit  persons  of  both  sexes 
to  membership  but  a  considerable  number  restrict  membership  to  one 
sex  or  the  other. 

All  fraternal  life  insurance  orders  have  age  qualifications  for  admis- 
sion to  beneficiary  membership  for  this  is  essential  as  a  matter  of  insur- 
ance practice.  The  minimum  age  requirement  ranges  from  12  to  21 
but  is  usually  16  or  18.  The  maximum  age  requirement  varies  from 
45  to  60;  the  ages  most  commonly  fixed  as  the  maximum  are,  in  the 
order  named,  50,  45,  55  and  60. 

(3)  The  life  insurance  contract  in  fraternal  insurance. — The  prin- 
cipal differences  between  the  policies  used  by  the  "old-line"  life  insur- 
ance companies  and  the  benefit  certificates  used  by  the  fraternal  life 
insurance  societies  have  been  described  as  follows : 

"The  ordinary  life-insurance  policy  is  simply  a  definite  promise  to 
pay,  in  return  for  a  fixed  consideration,  a  stipulated  sum  on  the  occur- 
rence of  the  specified  contingency,  and  contains  all  the  conditions  which 
govern  the  parties  to  the  contract.  In  this  respect  fraternal  societies 
follow  a  radically  different  plan.  Although  the  certificate  is  issued 
on  the  basis  of  an  application  which  is  similar  to  that  required  by 
regular  old-line  companies,  the  benefit  certificate  differs  from  an  ordi- 
nary policy  in  three  important  particulars : 

1.  The  certificate  is  comparatively  brief,  usually  stating  that  the 
holder  thereof  is  a  member  of  the  society,  that  he  is  entitled  to  all  its 
privileges  and  to  a  certain  portion  of  the  beneficiary  fund,  and  that  the 
society^s  promise  in  this  respect  is  conditioned  on  the  member's  com- 
pliance with  the  constitution  and  laws  of  the  society,  which  are  declared 
to  be  a  part  of  the  contract.  In  other  words,  the  benefit  certificate, 
unlike  an  ordinary  life-insurance  policy,  does  not  specify  in  detail  the 
conditions  which  govern  the  indemnity  agreement;  instead  these  are 
found  in  the  society's  rules. 
—29  HI 


450 

2.  The  certificate  merely  recognizes  the  holder's  rights  as  a  member 
in  the  society  for  a  specified  amount.  The  certificate  remains  the  prop- 
erty of  the  member,  who  is  usually  given  the  right  under  the  rules  to 
change  the  beneficiary  at  will,  while  the  ordinary  life-insurance  policy  is 
the  property  of  the  beneficiary  designated  therein  unless  the  insured  has 
expressly  reserved  the  right  in  the  contract  to  change  such  beneficiary  at 
will.  Usually  the  holder  of  a  benefit  certificate  can  only  name  as  bene- 
ficiary some  member  of  his  family  or  other  dependent. 

3.  The  certificate,  according  to  the  laws  of  most  states,  cannot  be 
an  agreement  promising  the  payment  of  a  definite  amount  for  a, fixed 
premium  as  is  the  case  with  old-line  companies.  From  a  practical  point 
of  view  the  most  important  difference  between  fraternal  and  old-line 
insurance  has  been  the  failure  of  the  formber  to  maintain  a  reserve  suffi- 
cient to  guarantee  the  pa^Tuent  of  all  obligations  as  they  mature^  In 
fact,  until  recently,  the  reserve  idea  was  bitterlv  opposed  by  most  fra- 
ternal orders  as  an  unnecessary  overcharge.  Instead  of  accumulating 
adequate  reserves,  the  societies  proceeded  on  the  plan  of  charging  low 
premiums  (which  experience  soon  demonstrated  to  be  Avoefully  inade- 
quate) and  reserved  to  themselves  the  right,  in  case  the  funds  on  hand 
should  prove  insufficient  to  meet  current  claims,  either  to  assess  their 
members  for  an  amount  equal  to  the  deficit  or  to  scale  down  the  amount 
of  the  benefit  so  as  to  make  its  payment  possible  with  the  funds  on  hand. 
In  reality,  therefore,  the  benefit  certificate  does  not  constitute  a  promise 
to  pay  a  definite  amount  for  a  definite  consideration.  Since  they  have 
not  promised  to  pay  more  than  the  funds  on  hand  together  with  the 
assessments  which  they  are  able  to  collect  from  their  members  enable 
them  to  pay,  fraternal  societies,  considering  the  matter  from  a  purely 
theoretical  standpoint,  cannot  become  insolvent.  Yet  a  very  large 
number  of  such  societies  have  passed  out  of  existence  as  utter  failures 
because  they  were  unable  to  obtain  sufficient  funds  through  assessments 
upon  their  members  to  pay  the  benefits  upon  which  the  members  were 
relying  for  the  protection  of  their  families  in  case  of  death  and  for 
which  they  had  been  contributing  for  years.''^'^ 

The  face  value  of  the  benefit  certificates  written  by  fraternal  life 
insurance  orders  operating  in  Illinois  range  from  $100,  in  the  case  of 
a  number  of  societies,  to  $10,000,  in  the  case  of  at  least  one  society. 
More  commonly  the  certificates  are  for  amounts  ranging  from  $250  to 
$2,000  or  $3,000.  In  some  of  the  societies  the  largest  certificate  issued 
is  for  $1,000;  this  is  true,  for  example,  of  a  number  of  Bohemian  and 
Polish  societies.  The  average  amount  per  certificate  in  force  in  Illinois 
on  December  31,  1917,  was  $l,116.i8 

The  kind  of  certificate  most  frequently  written  is  the  whole-life 
certificate  but  certificates  are  also  written  on  the  term,  limited  pa>Tiient 
and  endowment  plans  although  most  societies  do  not  offer  all  of  these 
forms.  Most  certificates  now  issued  provide  for  level  rates;  -some,  how- 
ever, are  written  on  the  step-rate  plan.  The  premiums  or  assessments 
are  usually  payable  monthly  but  some  societies  collect  them  8  or  10 

"Solomon  S.  Huebner,  Life  Insurance,  pp.  264-265. 
"Compare  data  shown  in  the  table  on  p.  448. 


451 


times  a  year  and  a  few  permit  them  to  be  paid  annually,  quarterly  or 
monthly  at  the  option  of  the  insured. 

(4)  The  cost  of  fraternal  life  insurance. — The  cost  of  fraternal 
life  insurance  naturally  varies  with  the  quality  of  the  insurance.  Poor 
insurance  can  be  purchased  at  low  rates;  good  insurance  on  the  basis 
of  rates  sufficient  to  create  an  adequate  reserve  costs  more.  The  follow- 
ing table  shows  the  net  cost  per  $1,000  of  life  insurance  at  different 
ages  on  the  basis  of  the  Xational  Fraternal  Congress  Table  of  Mortality 
and  an  assumption  of  4  per  cent  interest. ^^ 


NET  LEVEL  RATES — NATIONAL  FRATERNAL  CONGRESS  TABLE— FOUR 

PER  CENT  INTEREST. 


Age. 

Annual. 

Monthly. 

Age. 

Annual. 

Monthly. 

25 

$11. 92 
13.96 
16.62 
20.11 

$1.04 
1.22 
1.45 
1.75 

45 

$24.72 
30.98 
39.36 
51.13 

$2.16 

30 

50            .              

2.71 

35 

55                           

3.44 

40 

60.              

4.47 

Note. — No  provision  is  made  for  expense  loading  in  these  rates. 

Definite  information  secured  by  the  Commission  shows  that  at  least 
78  of  the  149  fraternal  life  insurance  societies  which  were  operating 
in  Illinois  in  1917  have  adopted  the  rates  illustrated  by  the  above  table 
or  higher  rates. -^  In  some  societies  the  rates  adopted  apply  to  old 
members  as  well  as  to  new  members;  in  other  societies  the  rates  apply 
to  new  members  only. 

The  expense  of  management  is  eared  for  in  various  ways.  The  most 
common  method  is  to  levy  a  per  capita  tax,  frequently  10  or  15  cents 
per  month  or  the  equivalent  rates  per  quarter  or  per  year.  Sometimes 
an  expense  loading  is  added  to  the  regular  premium.  Entrance  fees, 
certificate  fees,  and  funds  derived  from  the  sale  of  supplies  are  used 
to  defray  part  of  the  expense  of  management  in  some  orders.  A  por- 
tion of  the  assessments  for  the  first  year  or  the  first  few  months  of  the 
life  of  a  certificate  is  also  used  for  the  same  purpose  in  some  orders.^^ 

Reference  to  the  report  of  the  Superintendent  of  Insurance  for 
1918"-  shows  that  the  fraternal  life  insurance  societies  which  transacted 
business  in  Illinois  in  1917  received  from  their  Illinois  members  the 
sum  of  $15,298,169.51^^  and  paid  claims  in  Illinois  amounting  to  $14,- 
086,343.79  durinsj  the  vear.  These  data  cover  sick  and  accident  benefits, 
permanent  disability  benefits  and  other  benefits  provided  by  the  grand 
lodges  of  certain  fraternal  societies  as  well  as  the  life  insurance  pro- 
vided by  all  of  them,  but  it  is  probable  that  the  ratio  of  claims  paid  to 
receipts  from  members  on  the  entire  business  in  Illinois  will  be  approxi- 
mately accurate  for  the  life  insurance  business  alone.    This  ratio  is  92.1 

"Compiled  from  table  in  Statistics  Fraternal  Societies,  1918  edition,  p.  225. 

2°  Twenty-one  societies  use  higher  rates  than  those  illustrated  in  the  table  for 
part  or  all  of  the  certificates  which  they  now  write. 

^^  Statistics  Fraternal  Societies,  1918  edition,  pp.  7-192. 

"Insurance  Report  Illinois,  1918,  Part  II,  pp.  57-61. 

-3  This  sum  includes  only  payments  made  for  insurance  furnished  by  the  grand 
lodges.  It  does  not  include  dues  paid  for  other  purposes  either  to  the  local  lodges 
or  to  the  grand  lodges. 


452 

per  cent  for  the  year  1917.  The  amount  received  by  the  fraternal 
societies  in  1916  from  Illinois  members  was  $14,858,408.64  and  the 
amount  paid  in  claims  in  the  State  in  the  same  year,  $13,131,251.37,-* 
making  a  ratio  of  88.9  per  cent  for  1916.  Similar  data  for  earlier 
years  are,  unfortunately,  unavailable. 

The  report  of  the  Superintendent  of  Insurance  for  1918^^  shows  the 
following  totals  for  the  entire  business  in  the  United  States  and  else- 
where of  the  fraternal  societies  which  transacted  business  in  Illinois  in 
1917: 

Paid  by  members •  •  •  •       ^-"^^'ooo'c^Ann 

From   other   sources 16,233,560.99 

Total  receipts $139,530,226.75 

Disbursements —  »   «„  „^.  ..„  .- 

Paid  to  members $   93,994,117.41 

Expenses    ■ 24,866,265.33 

Total  disbursements   $118,860,382.74 

The  ratio  of  the  "amount  paid  to  members"  (claims  paid)  to  the 
amount  paid  by  members  for  the  entire  business  of  the  societies,  as 
shown  in  the  table,  is  76.2  per  cent,  which,  it  will  be  noted,  is  con- 
siderably lower  than  the  corresponding  ratio  for  the  Illinois  business 
alone.  The  ratio  of  the  amount  paid  to  members  to  the  total  receipts  is 
67.4  per  cent.  The  ratio  of  expenses  to  the  amount  paid  by  members 
for  the  entire  business  is  20.2  per  cent;  the  ratio  of  expenses  to  total 
receipts  is  17.8  per  cent.  The  ratio  of  expenses  to  total  receipts  was 
14.4  per  cent  in  1916  and  13.8  per  cent  in  1915.^®  No  data  are  avail- 
able to  show  the  expense  ratios  for  the  Illinois  business  alone. 

The  aggregate  membership,  as  distinguished  from  the  Illinois  mem- 
bership, of  the  fraternal  life  insurance  societies  which  operated  in  Illi- 
nois in  1917,  was  7,277,659  on  December  31,  1917.2^  The  division  of 
the  $24,866,265.33  shown  as  expenses  in  the  foregoing  table  among  this 
number  of  members  would  indicate  an  expense  of  $3.42  per  member 
for  the  year  1917.  This  amount  is  much  higher,  it  should  be  said,  than 
the  amounts  reported  in  the  1918  edition  of  "Statistics  Fraternal  Socie- 
ties" under  the  item  "cost  of  management  per  member^'  for  most  of  the 
societies  which  operated  in  Illinois  in  1917.  In  fact,  according  to 
the  compilation  cited,  the  "costs  of  management"  for  only  a  few  of 
these  orders  were  in  excess  of  $3.4^2  per  member  while  the  "costs  of 
management"  of  a  considerable  number  were  less  than  $1  per  member. 
It  appears  from  a  detailed  examination  of  the  records  for  individual 
societies  in  the  report  of  the  Superintendent  of  Insurance  and  in  the 
1918  edition  of  "Statistics  Fraternal  Societies"  that  the  term  "expenses" 
as  used  in  the  former  includes  some  items  that  are  excluded  from 
the  classification  "costs  of  management"  as  used  in  the  latter.  It  is 
impossible,  however,  to  determine  the  exact  difference  between  the  two 
classifications.  But  whatever  these  differences  may  be,  it  is  safe  to  say 
that  the  fraternal  life  insurance  orders  furnish  life  insurance  at  a  rela- 
tively low  operating  cost. 

"*  Insurance  Report  Illinois,  1917,  Part  II,  pp.  81-85. 
^^  Insurance  Report  IlUnois,  1918,  Part  II,  p.  61. 
^Insurance  Report  Illinois,  1917,  Part  II,  p.  15. 
^Insurance  Report  Illinois,  1918,  Part  II,  p.  13. 


• 


453 

The  comparatively  low  cost  of  operation  in  fraternal  life  insurance 
societies  is  due  to  a  number  of  causes.  The  organization  of  the  societies 
on  the  basis  of  the  lodge  system  makes  for  low  acquisition  of  business 
and  collection  costs.  The  fraternal  spirit,  which  is  strong  in  some  of 
the  societies,  also  aids  in  various  ways  in  keeping  down  expenses.  The 
salaries  and  other  compensation  paid  the  officers  and  employees  of  the 
fraternal  societies  are  low  as  compared  with  those  paid  the  officers  and 
employees  of  "old-line"  life  insurance  companies.  There  are  only  a  few 
fraternal  societies  in  the  United  States  in  which  the  total  compensation 
of  all  the  officers  and  trustees  will  equal  $50,000  per  year,  yet  there  is 
reason  to  believe  that  the  officers  of  some  of  the  larger  orders  are  equal 
in  ability  to  the  officers  of  some  of  the  larger  "old-line"  companies  in 
which  the  president  alone  is  paid  a  salary  of  $50,000  or  more  per  year. 
As  compared  with  stock  companies  in  the  life  insurance  business,  the 
fraternals  claim  that  they  have  an  advantage  in  not  being  compelled 
to  pay  dividends  to  stockholders. 

(5)  The  advantages  and  disadvantages  of  fraternal  life  insurance. 
— The  chief  advantage  of  the  fraternal  societies  as  carriers  of  life  insur- 
ance appears  to  be  the  relatively  low  operating  cost  which  has  just  been 
discussed.  Another  advantage,  which  is  important  in  influencing  some 
"prospects,"  is  the  fraternal  spirit  which  is  said  to  influence  the  rela- 
tions between  the  insured  and  the  insurer  in  fraternal  insurance  as 
contrasted  with  the  commercial  spirit  which  controls  the  relations 
between  the  insured  and  the  insurer  in  "old-line"  life  insurance  whether 
the  carrier  be  a  stock  company  or  a  mutual  company.  Concretely,  the 
fraternal  spirit  is  said  to  manifest  itself  in  such  ways  as  the  payment  by 
the  local  lodges  of  the  life  insurance  assessments  of  sick  or  indigent 
members  or,  to  take  a  recent  illustration,  the  assumption  by  the  mem- 
bers of  the  entire  order  of  the  burden  of  the  war  risk  arising  from  the 
enlistment  of  members  for  military  service.* 

Incidental  advantages  afforded  by  fraternal  life  insurance  include 
the  opportunities  for  social  intercourse  and  the  "training  for  citizen- 
ship" which  are  to  be  had  in  the  local  lodges.  The  privilege,  offered  in 
many  societies,  of  participating  in  sick  and  accident  benefits  and,  when 
necessary,  of  receiving  charitable  assistance  from  the  societies  is  also 
an  important  advantage  of  the  fraternal  insurance  plan. 

The  chief  disadvantage  of  fraternal  life  insurance  has  been  its 
unreliability.  The  causes  responsible  for  this  characteristic  have  been 
sufficiently  discussed  in  previous  pages  and  the  remedies  proposed  will 
be  considered  shortly.  To  some  persons  the  social,  fraternal  and  char- 
itable aspects  of  the  activities  of  the  fraternal  societies,  which  appear 
advantageous  to  the  rank  and  file  of  fraternal  society  membership,  are 
not  attractive  and  such  persons  commonly  prefer  the  more  "business- 
like" methods  of  the  old-line  companies. 

Whatever  the  relative  merits  of  fraternal  and  old-line  insurance 
may  be,  it  seeems  reasonable  to  infer  from  present  indications  that  both 
types  will  persist  for  an  indefinite  time  to  come.  The  fact  should  also 
be  recognized  that,  so  far  as  wage-earners  are  concerned,  each  type  of 
insurance  occupies  a  more  or  less  distinct  place.  While  a  considerable 
amount  of  "ordinary"  insurance  is  sold  to  wage-earners  by  the  old-line 


454 


companies,  the  majority  of  wage-earners  who  have  anything  approaciP 
ing  adequate  life  insurance  protection — and  most  of  it  is  far  from  adequate 
— carry  it  with  the  fraternal  societies.  The  industrial  life  insurance  sold 
by  some  of  the  old-line  companies  is  little  more  than  burial  insurance^^ 
and  is  not  to  be  compared  with  the  more  ample  protection  commonly 
purchased  by  the  holders  of  fraternal  certificates.  A  considerable  part 
of  the  industrial  life  insurance,  according  to  the  testimony  of  officers  of 
fraternal  societies,  is  sold  to  persons  who  are  able  to  buy  only  the  cheap- 
est and  least  desirable  form  of  life  insurance.  Much  of  the  industrial 
life  insurance,  moreover,  is  written  on  the  lives  of  children  and  the 
fraternal  societies  until  verv  recentlv  have  made  few  attempts  to  enter 
the  field  of  child  insurance.  From  the  standpoint  of  the  broad  problem 
of  finding  ways  and  means  of  improving  the  provision  of  health  and 
allied  forms  of  insurance  for  wage-earners  it  is  therefore  more  im- 
portant to  consider  possible  remedies  for  the  defects  of  fraternal  life 
insurance  than  to  continue  a  discussion  of  its  merits  as  compared  with 
other  forms  of  life  insurance. 

(6)  The  movement  for  the  establishment  of  adequate  reserves. — 
As  has  already  been  stated,  the  leaders  of  many  of  the  fraternal  societies 
have  recognized  the  need  for  the  establishment  of  adequate  reserves  and 
at  least  78  of  the  149  societies  which  were  operating  in  Illinois  in  1917 
have  adopted  rates  for  new  members,  if  not  always  for  old  members, 
which  are  based  on  the  National  Fraternal  Congress  table  and  an 
assumption  of  4  per  cent  interest  or  on  higher  standards.  There  is, 
however,  much  yet  to  be  accomplished.  It  is  still  possible  to  organize 
new  societies  in  Illinois  to  sell  insurance  on  inadequate  rates,  a  large 
number  of  the  societies  in  operation  have  not  adopted  rates  even  for  new 
business,  and  a  considerable  number  of  those  which  have  adequate  rates 
for  new  business  are  still  charging  inadequate  rates  on  their  old  business. 
A  recent  report  of  the  Commissioner  of  Insurance  for  Wisconsin  con- 
tains a  "valuation  exhibit"  for  the  fraternal  societies  authorized  to  trans- 
act business  in  Wisconsin.  This  exhibit  shows  (1)  the  "total  net  value 
of  outstanding  certificates  (required  reserve,''  (2)  "the  total  assets 
available  for  payment  of  future  death  claims,''  (3)  the  ratio  of  (2)  to 
(1).  Among  the  societies  included  in  the  exhibit  are  42  which  were 
operating  in  Illinois  as  well' as  in  Wisconsin  on  December  31,  1917,  the 
latest  date  shown  in  the  exhibit.  Of  the  42  societies  13  had  total  assets 
available  for  the  payment  of  future  death  claims  which  equalled  or  ex- 
ceeded the  total  net  value  of  outstanding  certificates  and  29  had  total 
assets  which  showed  deficits  ranging  from  97.5  per  cent,  in  the  case  of 
one  society,  to  14.3  per  cent,  in  the  case  of  another,  with  the  remainder 
of  the  29  fairly  well  scattered  between  the  two  extremes. 

The  progress  which  has  been  made  towards  the  establishment  of 
adequate  rates  and  reserves  among  the  fraternal  orders  in  recent  years 
has  been  accompanied  and  partly  caused  by  the  enactment  in  most  of  the 
states  of  legislation  designed  to  hasten  and  enforce  this  progress.  The 
meausres  enacted  commonly  follow  one  or  the  other  of  two  model  bills 
known,  respectively,  as  the  Mobile  Bill  and  the  New  York  Conference 
Bill. 


28  For  the  discussion  of  industrial  life  insurance  see  Part  II,  Special  Report  VIII. 


455 

The  Mobile  Bill  was  adopted  by  the  National  Convention  of  In- 
surance Commissioners,  at  Mobile,  Ala.,  September  28,  1910.  It  was 
concurred  in  by  Conference  Committies  representing  the  Associated 
Fraternities  of  America  and  the  National  Fraternal  Congress,  and  recom- 
mended by  them  for  enactment  into  law  in  the  various  states.  The 
New  York  Conference  Bill  consists  of  the  original  Mobile  Bill  as  modi- 
fied by  amendments  adopted  at  the  meeting  of  the  National  Convention 
of  Insurance  Commissioners  at  New  York,  December  11-12,  1911,  in 
conference  with  representatives  of  the  National  Fraternal  Congress  and 
the  Associated  Fraternities  of  America  and  amendments  adopted  at 
latei*  conferences  in  New  York  between  the  Insurance  Commissioners 
and  representatives  of  the  fraternal  organizations  mentioned. 

The  bills  are  designed  to  provide  a  complete  chapter  in  the  statutes 
for  the  "regulation  and  control  of  fraternal  benefit  societies."  The 
societies  are  to  be  exempt  from  all  other  insurance  laws  on  the  statute 
books  and  no  laws  enacted  in  the  future  are  to  apply  to  the  societies  un- 
less they  are  specifically  mentioned  in  the  laws.  The  bills  therefore 
set  forth  conditions  under  which  fraternal  benefit  societies  may  be 
organized  or  admitted  into  a  state  and  regulations  governing  the  char- 
acter of  benefits  which  may  be  provided,  the  choice  of  beneficiaries, 
membership  requirements,  the  nature  of  the  certificates  issued,  the  in- 
vestment of  funds,  the  liability  of  officers  of  a  society  for  the  payment 
of  benefits  (not  liable),  etc.  The  most  important  provisions  of  the  bill, 
for  the  purposes  of  this  study,  are  those  which  relate  to  the  valuation  of 
the  certificates  outstanding  against  the  societies  and  the  "provisions  to 
insure  future  security .^^     These  provisions  have  been  described  as  follows : 

The  bill  may  best  be  described  as  a  compromise,  concessions  having 
been  made  on  both  sides.  It  does  not  undertake  to  fix  the  net  rates  for 
any  order;  instead,  present  inadequate  rates  are  to  be  increased  grad- 
ually, and  this  policy  is  to  be  expedited  through  the  education  of  the 
fraternal  membership  to  the  necessity  of  such  an  increase.  The  bill,  as 
originally  drawn,  provided  that  after  1912  each  benefit  society  was  to 
report  to  the  insurance  department  a  valuation  of  its  certificates,  the 
minimum  basis  of  the  valuation  to  be  the  National  Fraternal  Congress 
table  of  mortality.  Since  such  a  valuation  is  sure  to  show  a  heavy  de- 
ficiency in  many  of  the  societies,  the  bill  further  provided  that  the  valu- 
ation was  not  to  be  considered  as  a  test  of  financial  solvency.  The  re- 
sults of  the  valuation,  however,  including  an  explanation  of  the  system, 
were  to  be  furnished  to  the  members  of  the  societies  beginning  in  1914, 
with  a  view  to  educating  them  to  the  need  of  higher  rates.  It  was  also 
provided  that  the  valuation  of  December  31,  1917,  must  be  reported  to 
the  insurance  departments,  and  that  if  the  admitted  assets  at  that  time 
prove  to  be  less  than  90  per  cent  of  the  reserve  and  other  liabilities,  the 
deficit  must  "show  a  reduction  of  at  least  5  per  cent  at  each  triennial 
valuation  thereafter,"  and  that  "if  such  a  reduction  has  not  been  made, 
and  no  good  reason  exists  the  insurance  department  may  proceed  to  can- 
cel the  society^s  license,  or  begin  proceedings  for  the  society's  dissolution.^' 
It  is  thus  seen  that  the  bill  grants  a  society  many  years,  in  case  of  a  large 
deficit,  in  which  to  place  itself  in  a  technically  solvent  condition.  Under 
the  bill  societies  are  also  enabled  to  group  their  membership.  New  mem- 
bers and  such  old  members  as  care  to  enter  the  plan  may  be  charged 


456 

adequate  rates  with  mathematical  reserves,  while  the  older  members 
may  be  permitted  to  continue  in  what  practically  amounts  to  a  separate 
order. -^ 

The  New  York  Conference  Bill,  including  amendments  of  1911, 
1912  and  1913,  provides  (section  23a)  that  '^if  the  valuation  of  the  cer- 
tficates  *  *  *  Qj^  December  31,  1917,  shall  show  that  the  present 
value  of  future  net  contributions,  together  Avith  the  admitted  assets,  is 
less  than  the  present  value  of  the  promised  benefits  and  accrued  liabili- 
ties, such  society  shall  thereafter  maintain  said  financial  condition  at 
each  succeeding  triennial  valuation  in  respect  of  the  degree  of  deficiency 
as  shown  in  the  valuation  as  of  December  31,  1917.^°  If  at  any  succeed- 
ing triennial  valuation  such  society  does  not  show  at  least  the  same  con- 
dition, the  Superintendent  shall  direct  that  it  thereafter  comply  with 
the  requirements  herein  specified.  If  the  next  succeeding  triennial 
valuation  after  the  receipts  of  such  notice  shall  show  that  the  society 
has  failed  to  maintain  the  condition  required  herein,  the  Superintendent 
may,  in  the  absence  of  good  cause  shown  for  such  failure,  institute  pro- 
ceedings for  the  dissolution  of  such  society     *     *     *      "si 

According  to  the  1918  edition  of  ^^Statistics  Fraternal  Societies" 
(page  207)  "at  the  beginning  of  1918  the  Mobile  and  New  York  Con- 
ference bills  were  in  operation  in  the  several  states  as  follows: 

New  Yorh  Conference  Bill:  Arizona,  Arkansas,  California,  Con- 
necticut, Florida,  Georgia,  Idaho,  Indiana,  Kentucky,  Louisiana,  Mary- 
land, Massachusetts,  Michigan,  Mississippi,  Missouri,  Montana,  New 
Hamphire,  New  York,  North  Carolina,  North  Dakota,  Oregon,  Rhode 
Island,  Tennessee,  Texas,  Utah,  Virginia,  Wisconsin,  Wyoming.  (28 
states.) 

Mobile  Bill,  without  the  New  York  Conference  amendments:  Ala- 
bama, Colorado,  Ohio,  Washington. 

The  folowing  states  have  the  old  National  Fraternal  Congress 
Uniform  Bill,  which  in  principle  is  the  same  as  the  New  York  Con- 
ference Bill,  except  as  to  those  sections  relating  to  valuation  and  public- 
ity: Iowa,  Maine,  Minnesota,  Oklahoma,  Vermont. 

In  South  Carolina  the  Mobile  Bill  is  practically  in  force  through 
departmental  rulings." 

The  experience  of  the  past  half  century  has  demonstrated  the  fact, 
which  was  well  known  to  actuaries  from  the  beginning,  that  neither 
private,  profit-seeking  enterprise  nor  the  cooperative  enterprise  of  the 
fraternal  societies  can  provide  satisfactory  life  insurance  at  equitable 
rates  and  at  the  same  time  disregard  fundamental  principles  of  sound 
insurance  practice.  The  old-line  companies  are  compelled  by  law  to 
provide  adequate  reserves.  The'  ethics  of  fair  competition  between  the 
fraternal  societies  and  the  old-line  companies  demand  that  such  fra- 
ternal socieites  as  have  not  already  done  so  be  compelled  to  make  similiar 
provision.  But  such  action  on  the  part  of  the  fraternal  socieites  is  even 
more  urgently  demanded  for  the  protection  of  the  purchasers  of  fra- 
ternal  certificates,  most  of  whom,  it  is  safe  to  say,  are  unable  in  advance 

"  Huebner,  Life  Insurance,  p.  270. 

•«  The  date  may  be  varied  according  to  date  of  enactment  of  the  bill. 

81  Solomon  S.  Huebner,  Life  Insurance,  p.  270.     Italics  by  the  present  writer. 


457 

of  experience,  to  distinguish  good  fraternal  insurance  from  poor  fraternal 
insurance. 

In  connection  with  the  problem  of  health  insurance  it  may  be  said 
that  the  usefulness  of  the  fraternal  orders  as  carriers  of  this  form  of 
insurance  would  undoubtedly  be  considerably  increased  if  all  of  the 
fraternal  life  insurance  orders  operating  in  Illinois  which  have  not  al- 
ready done  so  were  to  take  effective  steps  towards  the  creation  of  ade- 
quate reserves.  Such  action  should  make  it  much  easier  for  the  fra- 
ternal societies  to  increase  their  membership  and  hence  reach  more  of 
the  members  of  the  wage-earning  class  who  are  without  health  insurance. 
As  the  situation  stands  the  fraternal  societies  which  have  adopted  ade- 
quate rates  and  created  or  planned  effectively  for  the  creation  of  ade- 
quate reserves  have  to  suffer  from  the  poor  reputation  which  the 
unreliability  of  the  insurance  provided  by  other  fraternal  societies  has 
earned,  in  the  minds  of  many  persons,  for  fraternal  insurance  in 
general. 

The  enactment  of  the  Xew  York  Conference  Bill  or  the  Mobile 
Bill  in  the  states  which  have  been  enumerated  will  eventually,  if  the 
measures  as  they  stand  on  the  statute  books  are  not  weakened  by  amend- 
ments, compel  most  of  the  orders  operating  in  Illinois,  as  they  have 
already  induced  some,  to  adopt  adequate  rates  or  to  withdraw  from  the 
states  which  have  enacted  the  measure  mentioned.  The  enactment  of 
one  of  these  bills  in  Illinois,  or  of  an  effective  substitute,  would  hasten 
the  progress  being  made  by  the  fraternal  societies  towards  the  establish- 
ment of  all  fraternal  life  insurance  on  a  scientific  basis.  It  would  also 
affect  some  orders  which  are  now  operating  only  in  Illinois  as  well  as 
prevent  the  further  increase  of  unsound  fraternal  insurance  in  the  State. 

It  is  well  known  that  some  societies  in  Illinois  would  have  difficulty 
in  inducing  their  members  to  meet  the  requirements  of  the  measures 
under  discussion.  All  reasonable  consideration  should  be  shown  such 
societies  but  the  fact  should  be  recognized  that  the  welfare  of  the  mem- 
bers of  fraternal  societies  as  a  whole  and  the  need  of  the  State  for  sound 
insurance  are  more  important  than  the  difficulties  of  individual  societies 
which  have  persisted  in  attempting  to  accomplish  what  has  long  been 
demonstrated  to  be  impossible. 

III.  Whole  Family  Protection. 

(1)  Nature  of  the  plan. — "Whole  family  protection,"  or  juvenile  or 
child  insurance  as  it  is  sometimes  more  accurately  called,  is  a  very  recent 
development  in  the  field  of  fraternal  insurance.  It  is  so  recent,  in  fact, 
that  the  statistical  data  gathered  by  the  Commission  with  reference  to 
the  operation  of  the  plan  in  Illinois  have  little  significance  except  as 
they  show  the  number  of  societies  which  had  made  provision  for  the 
plan  at  the  time  the  data  were  gathered.  The  discussion  which  follows 
will  therefore  be  confined  chiefly  to  a  description  of  the  nature  and 
purposes  of  the  plan. 

Briefly  stated,  the  primary  purpose  of  whole  family  protection  is  to 
enable  members  to  secure  from  the  societies  the  assurance  of  funeral 
benefits  for  their  children  or  for  children  for  whose  care  they  may  be 
responsible.  Because  the  death  of  children  is  the  frequent  result  of 
sickness  in  the  families  of  wage-earners  as  well  as  the  cause  of  more  or 


458 

less  serious  drains  on  their  financial  resources  the  Commission  deemed 
an  investigation  of  whole  family  protection  advisable. 

An  argument  used  by  the  fraternal  societies  in  urging  the  passage 
of  legislation  permitting  the  societies  to  furnish  this  new  form  of  in- 
surance is  that  the  insurance  is  needed  to  supplement  that  provided  by 
the  industrial  life  insurance  companies  which  have  heretofore,  with 
a  few  exceptions,  been  the  only  carriers  Avho  insured  the  lives  of  children. 
As  stated  in  a  Ibrief  which  has  been  presented  to  the  legislatures  of  a 
number  of  states  by  representatives  of  the  National  Fraternal  Congress. 

"Industrial  companies  insure  the  lives  of  children,  but  they  confine 
their  operations  to  congested  districts.  Under  their  methods  for  col- 
lecting premiums  it  is  impractical  for  them  to  operate  in  sparsely 
settled  communities;  in  fact,  their  activities  are  confined  to  cities  or 
urban  communities.  The  expense,  if  their  business  were  extended  to 
rural  districts,  would  be  prohibitive.  In  these  circumstances  persons 
who  did  not  live  in  cities  are  deprived  of  the  privilege  of  insuring  their 
children.  *  *  *  rj^j^g  Fraternal  Benefit  Societies  operate  largely  in 
the  rural  districts  and  the  members  pay  their  assessments  to  the  clerks 
of  local  lodges.  It  would  require  but  little  additional  expense  to  have 
these  clerks  collect  dues  for  members^  insured  children,  the  machinery 
for  the  same  being  already  in  operation.^^ 

Two  motives  other  than  the  desire  to  provide  juvenuile  insurance 
for  members  living  in  country  districts  appear  also  to  have  actuated 
the  fraternal  societies  which  have  adopted  the  whole  family  protection 
plan.  The  first  has  been  a  desire  to  increase  the  membership  of  the 
societies  by  making  a  wider  appeal  to  adults  but  especially  by  accustom- 
ing the  children  of  the  memlDcrs  to  the  nature  and  spirit  of  fraternal 
insurance  so  that  they  will  be  ready  to  become  members  when  they 
reach  the  age  of  eligibility.  The  second  motive  has  been  a  desire  to 
meet  the  competition  of  the  industrial  life  insurance  companies  more 
effectively  in  cities  like  Chicago  as  well  as  in  smaller  cities  where  the 
fraternal  societies  and  the  industrial  companies  come  into  more  or  less 
competition  with  each  other.  The  secretaries  of  the  grand  lodges  of 
several  societies  have  informed  representatives  of  the  Commission  that 
they  expect  to  compete  successfully  with  the  industrial  companies 
because  of  the  superior  economy  claimed  for  the  fraternal  society  plan 
of  soliciting  business  and  collecting  dues. 

The  details  of  the  whole  family  protection  plan  can  perhaps  best 
be  made  clear  by  a  reading  of  the  simple  language  of  the  model  whole 
family  protection  bill  which  was  enacted  into  law  in  Illinois  at  the  last 
session  of  the  Legislature.  This  bill  was  prepared  by  the  National 
Fraternal  Congress  and  approved  by  the  National  Convention  of  Insur- 
ance Commissioners  at  New  York  City  on  December  13,  191 6.  The 
bill  as  enacted  into  law  in  Illinois  follows: 

"Section  2a.  Any  fraternal  benefit  society  authorized  to  do  business 
in  this  State  and  operating  on  the  lodge  plan,  may  provide  in  its  consti- 
tution and  by-laws,  in  addition  to  other  benefits  provided  for  therein, 
for  the  payment  of  death  or  annuity  benefits  upon  the  lives  of  children 
between  the  ages  of  two  and  eighteen  years  at  next  birthday,  for  whose 
support  and  maintenance  a  member  of  such  society  is  responsible.    Any 


459 

such  society  may  at  its  option,  organize  and  operate  branches  for  such 
children  and  membership  in  local  lodges  and  initiation  therein  shall  not 
be  required  of  such  children,  nor  shall  they  have  any  voice  in  the  man- 
agement of  the  society.  The  total  benefits  payable  as  above  provided 
shall  in  no  case  exceed  the  following  amounts  at  ages  at  next  birthday 
at  time  of  death,  respectively,  as  follows :  two.  Thirty-four  Dollars ; 
three,  Forty  Dollars ;  four.  Forty-eight  Dollars ;  five,  Fifty-eight  Dollars ; 
six,  One  Hundred  and  forty  Dollars;  seven.  One  Hundred  and  sixty- 
eight  Dollars;  eight,  Two  Hundred  Dollars;  nine,  Two  Hundred  and 
forty  Dollars;  ten,  Three  Hundred  Dollars;  eleven,  Three  Hundred  and 
eighty  Dollars;  twelve.  Four  Hundred  and  sixty  Dollars;  thirteen  to 
fifteen.  Five  Hundred  and  twenty  Dollars ;  and  sixteen  to  eighteen  years, 
where  not  otherwise  authorized  by  law.  Six  Hundred  Dollars. 

"Section  2b.  No  benefit  certificate  as  to  any  child  shall  take  effect 
until  after  medical  examination  or  inspection,  in  accordance  with  the 
lav/s  of  the  society,  nor  shall  any  such  benefit  certificate  be  issued  unless 
the  society  shall  simultaneously  put  in  force  at  least  five  hundred  such 
certificates,  on  each  of  which  at  least  one  assessment  has  been  paid,  nor 
where  the  number  of  lives  represented  by  such  certificate  falls  below 
five  hundred.  The  death  benefit  contributions  to  be  made  upon  such 
certificate  shall  be  based  upon  the  "Standard  Industrial  Mortality, Table" 
or  the  "English  Life  Table  Number  Six"  and  a  rate  of  interest  not 
greater  than  4  per  cent  per  annum,  or  upon  a  higher  standard :  Pro- 
vided, that  contributions  may  be  waived  or  returns  may  be  made  from 
any  surplus  held  in  excess  of  reserve  and  other  liabilities,  as  provided 
in  the  by-laws :  And,  provided  further,  that  extra  contributions  shall 
be  made  if  the  reserves  hereafter  provided  for  become  impaired. 

"Section  2c.  Any  society  entering  into  such  insurance  agreements 
shall  maintain  on  all  such  contracts  the  reserve  required  by  the  standard 
of  mortality  and  interest  adopted  by  the  society  for  computing  contri- 
butions as  provided  in  section  2b,  and  the  funds  representing  the  benefit 
contributions  and  all  accretions  thereon  shall  be  kept  as  separate  and 
distinct  funds,  independent  of  the  other  funds  of  the  society,  and  shall 
not  be  liable  for,  nor  used  for  the  payment  of  the  debts  and  obligations 
of  the  society  other  than  the  benefits  herein  authorized :  Provided,  that 
a  society  may  provide  that  when  a  child  reaches  the  minimum  age 
for  initiation  into  membership  in  such  society,  any  benefit  certificate 
issued  hereunder  may  be  surrendered  for  cancellation  and  exchanged 
for  any  other  form  of  certificate  issued  by  the  society:  Provided,  that 
such  surrender  will  not  reduce  the  number  of  lives  insured  in  the 
branch  below  five  hundred,  and  upon  the  issuance  of  such  new  certifi- 
cate any  reserve  upon  the  original  certificate  herein  provided  for  shall 
be  transferred  to  the  credit  of  the  new  certificate.  Neither  the  person 
who  originally  made  application  for  benefits  on  account  of  such  child, 
nor  the  beneficiary  named  in  such  original  certificate,  nor  the  person 
who  paid  the  contributions,  shall  have  any  vested  right  in  such  new  cer- 
tificate, the  free  nomination  of  the  beneficiary  under  the  new  certificate 
being  left  to  the  child  so  admitted  to  benefit  membership. 

"Section  2d.  An  entirely  separate  financial  statement  of  the  busi- 
ness transactions  and  of  assets  and  liabilities  arising  therefrom  shall  be 


460 

made  in  itse  annual  report  to  the  Insurance  Superintendent  by  any 
society  availing  itself  of  the  provisions  hereof.  The  separation  of  assets, 
funds  and  liabilities  required  hereby  shall  not  be  terminated,  rescinded 
or  modified,  nor  shall  the  funds  be  diverted  for  any  use  other  than  as 
specified  in  section  2c,  as  long  as  any  certificates  issued  hereunder 
remain  in  force,  and  this  requirement  shall  be  recognized  and  enforced 
in  any  liquidation,  reinsurance,  merger  or  other  change  in  the  condi- 
tion of  the  status  of  the  society. 

Section  2e.  Any  society  shall  have  the  right  to  provide  in  its  laws 
and  the  certificate  issued  hereunder  for  specified  payments  on  account 
of  the  expense  or  general  fund,  which  payments  shall  or  shall  not  be 
mingled  with  the  general  fund  of  the  society  as  its  constitution  and 
by-laws  may  provide. 

"Section  2f.  In  the  event  of  the  termination  of  membership  in  the 
society  by  the  person  responsi'tia  for  the  support  of  any  child,  on  whose 
account  a  certificate  may  have  i)cen  issued,  as  provided  herein  the  cer- 
tificate may  be  continued  for  the  benefit  of  the  estate  of  the  child: 
Provided,  the  contributions  are  continued,  or  for  the  benefit  of  any  other 
person  responsible  for  the  support  and  maintenance  of  such  child,  who 

shall  assume  the  payment  of  the  required  contributions.  (In  force  Julv 
1,  1917). "32 

(2)  Present  status  of  whole  family  protection  in  Illinois. — The  in- 
formation upon  which  the  present  discussion  of  whole  family  protection 
is  based  was  gathered  at  various  times  during  the  months  from  July 
to  September,  inclusive,  in  the  year  1918.  The  data  obtained  show  that 
of  the  149  societies  authorized  to  write  life  insurance  in  the  State,  at 
least  27,  with  311,273  members,  had  taken  steps  to  provide  this  whole 
family  protection.  Nine  of  these,  with  150,952  members,  had  already 
placed  the  plan  in  operation. 

As  has  been  indicated  above,  the  whole  family  protection  law  did 
not  go  into  effect  in  Illinois  until  July  1,  1917.  After  the  law  went  into 
effect  societies  desiring  to  take  advantage  of  it  had  to  adopt  the  plan 
at  their  regular  conventions  or  otherwise  as  prescribed  in  their  laws, 
if  they  had  not  already  authorized  its  adoption.  Several  societies  have 
had  the  plan  under  consideration  for  some  time  but  have  postponed  its 
adoption  because  of  war  conditions  or  because  of  conditions  incident  to 
attempts  to  change  their  business  from  an  inadequate  to  an  adequate 
rate  basis.  Because  of  these  facts  the  experience  with  whole  family 
protection  in  Illinois  up  to  the  time  at  which  the  Commission  closed 
its  investigation  of  this  subject  was  too  limited  to  make  a  detailed  exam- 
ination of  this  experience  of  any  value. 

(3)  Advantages  and  disadvaiitages  of  the  whole  family  protection 
plan— It  is  apparent  from  a  reading  of  the  model  whole  family  protec- 
tion bill  as  embodied  in  the  Illinois  law  quoted  above  that  this  new 
form  (.r  insurance  has  been  well  safe-guarded  by  the  terms  of  this 
measure.  The  insurance  is  placed  on  a  legal  reserve  basis  and  the 
maximum  amount  which  can  be  carried  on  the  life  of  a  child  is  properly 
limited  in  accordance  with  the  age  of  the  child  in  order  to  eliminate 
the  moral  hazard  which  may  exist  if  a  child  is  over-insured.    The  rates 

*^Inaurance  Laws  of  the  State  of  Illinois,  1917,  pp.  98-100. 


461 


charged  by  fraternal  societies  which  have  adopted  the  plan  for  nse  in 
Illinois  appear  to  be  relatively  low  as  is  indicated  by  the  following  state- 
ment of  the  rates  charged  by  a  society  which  reported  that  it  was  to 
begin  the  writing  of  certificates  under  the  plan  in  Illinois  during  the 
snmmer  of  1918 : 

RATE  OF  MONTHLY  ASSESSMENT  FOR  CHILDREN. 
Ordinary  Whole  Life  Certificate — Monthly  Ratb^  25c — Schedule  of  Benefits. 


Amount  payable  if  certificate  has 
been  in  force  for — 


Age  next  birthday  at  date  of  certificate. 


10 


11     12 


13 


14 


15 


16 


1st  6  months. 
2nd  6  months 

1  year 

2  years 

3  years 

4  years 

5  years 

6  years 

7  years 

8  years 


$17 

$  20 

$  24 

$  29 

$  38 

$  50 

$  63 

$  75 

$  80 

$  78 

$  75 

$  73 

$  70 

$68 

34 

40 

48 

58 

70 

90 

125 

150 

160 

155 

150 

145 

140 

135 

40 

48 

58 

70 

90 

125 

150 

165 

48 

58 

70 

90 

125 

165 

175 

58 

70 

90 

125 

165 

185 

70 

90 

125 

165 

195 

90 

125 

165 

200 

125 

165 

205 

165 

210 

215 

$65 
130 


The  above  certificate  may  be  continued  at  25c  per  month  after  age  16  until  death 
for  maximum  amount,  based  on  age  at  entry. 

TERM   CERTIFICATE. 
Term  to  Age  16 — Monthly  Rate,   15c — Schedule  of  Benefits. 


Amount  payable  if  certificate  has 
been  in  force  for — 


Age  next  birthday  at  date  of  certificate. 


10 


11 


12 


13 


14 


15 


16 


1st  6  months 
2d  6  months. 

1  year 

2  years 

3  years 

4  years 

5  years 

6  years 

7  years 

8  years 

9  years 

10  years 

11  years 

12  years 

13  years 

14  years 


$17 

$  20 

$  24 

$  29 

$  35 

$  42 

$  50 

$  60 

$  71 

$  83 

$  96 

$110 

$125 

$125 

34 

40 

48 

58 

70 

84 

100 

120 

142 

166 

192 

220 

250 

250 

40 

48 

58 

70 

84 

100 

120 

142 

166 

192 

220 

250 

250 

250 

48 

58 

70 

84 

100 

120 

142 

166 

192 

220 

250 

250 

250 

58 

70 

84 

100 

120 

142 

166 

192 

220 

250 

250 

250 

70 

84 

100 

120 

142 

166 

192 

220 

250 

250 

250 

M 

100 

120 

142 

166 

192 

220 

250 

250 

250 

100 

120 

142 

166 

192 

220 

250 

250 

250 

120 

142 

166 

192 

220 

250 

250 

250 

142 

166 

192 

220 

250 

250 

250 

166 

192 

220 

250 

250 

250 

192 

220 

250 

250 

250 

220 

250 

250 

250 

250 

250 

250 

250 

250 

250 

$125 
250 


The  above  rate  provides  for  insurance  until  age  16  only  when  the  benefits  and 
payments  terminate. 


N"o  important  disadvantages  in  the  whole  family  protection  plan 
have  been,  brought  to  the  attention  of  the  Commission.  All  things  con- 
sidered, it  seems  safe  to  conclude,  as  did  the  Legislature  of  1917,  that 
the  plan  is  one  that  promises  to  be  of  material  assistance  to  the  wage- 
earners  of  the  State  and  others  interested  in  securing  the  insurance  of 
funeral  benefits  on  the  lives  of  children. 


462 

IV.  Fraternal  Health  and  Accident  Insurance. 

(1)  Nature  and  developmeiit  of  fraternal  health  and  accident  in- 
surance.— The  principal  forms  of  health  and  accident  insurance  pro- 
vided by  the  fraternal  orders  are  the  "sick  and  accident  benefits"  which 
are  paid  in  many  of  them  for  loss  of  time  resulting  from  sickness  or 
accidental  injury.  Frequently  the  term  "sick  benefit"  is  used  to  include 
both  types  of  insurance — a  practice  which  is  explained  by  the  fact  that 
tlie  same  benefits  are  commonly  paid  for  loss  of  time  resulting  from 
accidental  injuries  as  for  loss  of  time  resulting  from  sickness.  In  addi- 
tion to  sick  and  accident  benefits,  benefits  for  specific  losses,  such  as 
loss  of  limb,  sight  or  hearing,  and  benefits  for  total  and  permanent 
disability  or  old  age  disability  are  provided  in  a  considerable  number  of 
societies. 

The  history  of  fraternal  sick  and  accident  benefits  in  the  United 
States  has  yet  to  be  written.  It  is  impossible,  without  a  more  detailed 
investigation  than  the  time  at  the  disposal  of  the  Commission  permitted, 
even  to  sketch  the  outlines  of  this  history.  It  must  suffice  to  say  that 
the  fraternal  societies  in  the  United  States  have  had  a  long  experience 
ill  the  provision  of  sick  and  accident  benefits  during  which  they  have 
paid  many  millions  of  dollars  in  these  benefits  to  their  members  and 
that  to-day  they  are  providing  more  wage-earners  with  health  insurance 
than  any  other  class  of  insurance  carrier  in  the  country. 

(2)  Fraternal  health  and  accident  insurance  in  Illinois. — In  Illi- 
nois, as  in  the  United  States  as  a  whole,  the  fraternal  societies  are  the 
]irincipal  carriers  of  health  and  general  accident  insurance^^  for  wage- 
earners.  The  sick  and  accident  benefits  provided  by  a  society  may  be 
paid  by  the  grand  lodge  or  by  the  local  lodges  or  they  may  be  paid  by 
both,  as  the  constitution  and  by-laws  of  the  society  may  direct  or  per- 
mit. The  provision  of  benefits  by  the  local  lodges  may  be  made  com- 
pulsory upon  them  in  the  constitution  and  by-laws  of  the  society  or  it 
may  be  left  optional  with  them.  In  some  societies,  of  course,  neither 
the  grand  lodge  nor  the  local  lodges  pay  sick  or  accident  benefits.  No 
reports  of  the  sick  and  accident  benefits  paid  are  made  to  the  Superin- 
tendent of  Insurance  in  this  State,  except  in  the  case  of  societies  which 
provide  these  benefits  through  the  grand  lodge,  and  only  a  few  of  the 
societies  in  which  the  benefits  are  paid  by  the  local  lodges  have  collected 
statistics  of  the  amounts  so  paid.  The  Commission,  as  stated  on  a 
previous  page,  sent  questionnaires  to  4,900  local  lodges  and  received 
returns  from  1,871  of  them.  It  is  therefore  impossible  to  present  com- 
plete and  exact  data  in  respect  either  to  the  amount  of  health  and  acci- 
dent insurance  carried  by  the  fraternal  societies  for  members  of  the 
wage-earning  class  in  Illinois  or  the  number  of  persons  in  this  class 
who  are  protected  by  this  insurance. 

The  report  of  the  Superintendent  of  Insurance  for  1918  shows  that 
50  fraternal  insurance  societies  which  transacted  business  m  Illinois 
during  the  year  1917,  and  which  had,  on  December  31,  1917,  a  total 
membership  of  265,799  persons  in  the  State,  had  made  provision  for 

anoir.Jf^fr,!?,^'"  "general   accident  insurance"   is  here  used  to   distinguish  ordinary 
acclaent  insurance  from  workmen's  compersation. 


463 

the  payment  of  sick  and  accident  benefits^*  for  their  members  through 
their  grand  lodges.  Six  of  these  societies  paid  no  sick  and  accident 
benefits  in  Illinois  during  the  year  mentioned;  the  remaining  44,  with 
a  total  membership  of  263,832  persons,  paid  6,842  claims,  amounting  to 
$242,440.57  to  Illinois  members  during  the  year.^^ 

The  term  "sick  and  accident  benefits"  as  used  in  the  reports  of  the 
Superintendent  of  Insurance  includes  both  indemnity  paid  for  loss  of 
time  and  indemnity  paid  for  specific  injuries,  such  as  the  loss  of  a  limb 
or  the  loss  of  sight  or  hearing.  The  reports  do  not  separate  the  amounts 
paid  for  the  two  classes  of  benefits  and  it  is  impossible  to  obtain  complete 
information  in  this  matter  from  any  other  source.  The  Commission  has 
information,  however,  which  shows  that  at  least  12  of  the  50  societies 
do  not  pay  benefits  for  loss  of  time.  These  societies,  with  an  aggregate 
membership  in  Illinois  of  92,600  persons  on  December  31,  1917,  paid 
specific  injury  benefits  amounting  to  $25,870.95  on  268  claims  in  Illi- 
nois during  the  year  1917. ^'^  Of  the  remaining  38  societies  29  advised 
the  Commission  that  they  pay  benefits  for  loss  of  time.  These  societies 
had  a  total  membership  of  141,832  persons  on  December  31,  1917. 
Some  of  these  societies  pay  sj^ecific  injury  indemnities  as  well  as  benefits 
for  loss  of  time  but  data  are  not  available  to  show  how  much  they  paid 
in  each  class  of  benefit  in  1917  or  in  any  other  year. 

The  foregoing  discussion  leaves  9  societies  of  the  50  unaccounted 
for.  Of  the  9,  one  has  informed  the  Commission  that  the  sick  and 
accident  benefits  which  it  pays  through  the  grand  lodge  are  paid  "in 
case  of  need  and  misfortune  of  members" — which  suggests  that  they 
are  paid  as  a  matter  of  charity  rather  than  as  insurance;  another  has 
reinsured  its  members  in  an  assessment  accident  and  health  association 
and  has  ceased  doing  business;  and  a  third  still  pays  sick  and  accident 
benefits  on  certain  old  contracts  but  does  not  write  new  certificates  pro- 
viding for  such  benefits.  No  information  has  been  obtained  concerning 
the  character  of  the  sick  and  accident  benefits  provided  by  the  remain- 
ing 6  societies. 

In  addition  to  the  50  societies  shown  in  the  report  of  the  Superin- 
tendent of  Insurance  for  1918  as  having  made  provision  for  the  pay- 
ment of  sick  and  accident  benefits  3  small  societies  not  so  shown  have 
reported  to  the  Commission  that  they  paid  such  benefits  in  1917  and 
that  they  still  make  provision  for  them.  These  societies,  with  a  total 
membership  of  7,325  at  the  close  of  the  year  mentioned,  paid  760  claims 
amounting  to  $31,604.42  during  the  year.^^  The  sick  and  accident 
benefits  paid  by  these  societies  are  for  loss  of  time  only. 

3*  A  number  of  the  societies  pay  benefits  for  accidents  only.  One  society  shown 
in  Superintendent  Potter's  report  is  excluded  from  the  statement  above  for  the 
reason  that  it  had  no  members  in  Illinois  at  the  end  of  the  year.  Data  shown  in 
statement  obtained  from  Insurance  Report  Illinois,   1918,  Part  II,  pp.   373-619. 

2^'  Averages  based  on  these  figures  are  omitted  because  they  are  of  little  signifi- 
cance. Only  part  of  the  members  are  insured  against  sickness  and  accidents — and 
it  IP  impossible  to  say  how  many — and  the  benefits  paid  vary  considerably  in 
chaiacter. 

2"  These  benefits  were  paid  by  8  of  the  12  societies;  the  remaining  4  paid  no 
specific  injury  benefits  in  Illinois  in  1917.  The  membership  of  the  8  societies  was 
90,633  on  December  31,  1917. 

"One  society,  with  a  membership  of  about  4,000  on  December  31,  1917,  paid  657 
of  the  760  claims  amounting  to  $27,450.69. 


464 

Summarizing  the  above  discussion,  it  may  be  said  tha-t  the  data 
available  to  the  Commission  show  definitely  that  32  fraternal  life  insur- 
ance societies  which  operated  in  Illinois  in  1917  provide  benefits  through 
their  grand  lodges  for  loss  of  time  resulting  from  sickness  or  accidental 
injuries,  and  indicating  that  few,  if  any  of  the  remaining  117  societies 
make  such  provision  for  their  members. 

Returns  showing  in  more  or  less  detail  the  character  of  the  pro- 
vision, if  any,  made  for  sickness  and  accidents,  were  received  from  122 
of  the  149  fraternal  life  insurance  orders  which  operated  in  Illinois 
in  1917,^®  including  the  32  mentioned  above.  These  returns  throw  a 
good  deal  of  light  upon  the  nature  of  the  health  and  accident  insurance 
carried  by  the  fraternal  orders.  The  following  table  contains  a  classi- 
fication of  the  122  societies  according  to  the  kind  of  insurance  provided 
and  the  method  of  administration  used. 


Classification  of  societies. 


Number 

of 
societies.* 


Aggregate 
member- 
ship in 
Illinois, 
Dec.  31, 
1917. 


Societies  in  which  the  grand  lodge  provides  sick  and  accident  benefits  for  loss 

of  time 

Socieites  in  which  the  grand  lodge  provides  specific  injury  benefits  % 

Societies  in  which  the  provision  of  sick  benefits**  is  compulsory  upon  the  local 

lodges 

Societies  in  which  the  provision  of  sick  benefits**  is  optional  with  the  local 

lodges 

Societies  in  which  no  provision  is  made  for  sick,  accident  or  specific  injury 

benefitsft 


146,495 

255, 881 

56,797 
686,762 
130,139 


•  Some  societies  appear  in  two  or  more  classifications ;  totals  are  therefore 
omitted  as  meaningless. 

t  Tw^o  societies  provide  accident  benefits  only. 

}.  Usually  apply  only  to  accidental  injuries,  but  in  some  societies  cover  losses 
occasioned  by  disease  as  vi^ell  as  those  occasioned  by  accidental  injuries,  as,  e.  g., 
loss  of  sight  or  hearing  or  paralysis  resulting  from  disease. 

*•  The  "sick  benefits"  provided  by  the  local  lodges  usually  cover  loss  of  time 
from  accidental  injuries  as  well  as  loss  of  time  from  sickness. 

ft  One  society  has  an  auxiliary  association  which,  among  other  things,  main- 
tains a  tuberculosis  sanatorium  for  members  who  can  afford  to  pay  for  its  services 
as  well  as  for  indigent  members. 

Information  similar  to  that  shown  in  the  foregoing  table  was 
sought  from  a  number  of  fraternal  societies  which  are  not  classified  as 
life  insurance  orders  but  which  were  known  or  thought  to  be  providing 
sick  benefits  through  the  local  lodges.  Because  of  the  lack  of  time  and 
funds  required  to  make  a  personal  canvas  of  these  societies  the  investiga- 
tion of  their  activities  was  made  chiefly  by  correspondence.  A  number 
presented  the  Commission  with  all  the  information  asked  for  by  it 
but  unfortunately  a  number  of  others  failed  to  make  any  reply  to  the 

"  Information  incomplete  for  4  of  the  126  societies  mentioned  on  p.  3. 


465 

requests  made  of  them.     Data  obtained  from  nine  societies  show  the 
following  results : 


Classification  of  societies.  - 

Number 

of 
societies. 

Aggregate 
member- 
ship in 
Ilhnois, 
1918. 

Societies  in  which  the  provision  of  sick  benefits  is  compulsory  upon  the  local 
lodges 

4 
4 

1 

146, 752 

Societies  in  which  the  provision  of  sick  benefits  is  optional  with  the  local  lodges 
Societies  in  which  sick  benefits  are  provided  by  auxiliary  sick  benefit  associa- 
tions  

55,791 
*2,000 

Total 

9 

204,543 

*  Membership  of  parent  society.     Membership  optional  in  auxiliary  societies  and 
number  of  members  not  reported. 

(3)  Sick  and  accident  benefits  provided  by  the  grand  lodges. — 
Reference  to  the  last  table  but  one  will  reveal  the  fact  that  32  of  the 
122  fraternal  life  insurance  societies  included  in  the  table  provide  sick 
and  accident  benefits  for  loss  of  time  through  the  grand  lodges. 

Data  regarding  the  nature  and  amount  of  the  benefits  provided  for 
loss  of  time  resulting  from  sickness  and  accidental  injuries  and  the  rules 
governing  eligibility  to  receive  these  benefits  were  gathered  through  the 
questionnaires  returned  by  these  societies.  These  data  show  that  in  17 
of  the  32  societies  members  eligible  for  health  and  accident  insurance 
may  exercise  their  option  in  purchasing  it  while  in  10  societies  member- 
ship as  a  beneficiary  member  (that  is,  a  member  carrying  life  insurance) 
ipso  facto  entitles  a  member  to  health  and  accident  insurance  and  requires 
him  to  pay  for  it.  The  information  received  for  the  remaining  5  societies 
indicates  that  almost  all  of  their  members  carry  the  sick  and  accident 
benefits  provided  but  does  not  disclose  whether  such  action  is  optional 
or  obligatory.  In  some  of  the  societies  where  the  benefits  are  optional 
with  the  members  less  than  10  per  cent — in  two  less  than  one  per  cent — 
take  advantage  of  them;  in  others,  a  large  proportion  make  use  of  the 
privilage.  All  in  all,  the  questionnaires  returned  to  the  Commission  in- 
dicate that  an  aggregate  of  about  60,000  persons  carry  loss  of  time  dis- 
ability benefits  of  one  kind  or  another  with  the  32  societies  which  furnish 
these  benefits  through  the  grand  lodges.  How  many  of  these  are  members 
of  the  wage-earning  class  it  is  impossible  to  say  definitely,  but  it  is 
probably  safe  to  say  that  at  least  two-thirds  of  the  60,000  or  about  40,000, 
can  be  so  classified. 

Benefits  paid  by  the  grand  lodges  for  loss  of  time  are  usually  ex- 
pressed as  so  much  per  week  but  they  are  sometimes  fixed  at  so  much 
per  month  or  so  much  per  day.  The  range  of  the  benefits  reported  to  the 
Commission  by  the  32  societies  mentioned  above  is  from  $2.50  per  week, 
which  was  one  of  several  benefits  provided  by  one  society,  to  $120  per 
month  which  was  the  largest  benefit  paid  by  another  society.  Two 
societies  reported  minimum  benefits  of  $3.50  per  week,  one  a  minimum 
benefit  of  $4  per  week,  ten  a  minimum  benefit  of  $5  per  week,  one  a 
minimum  benefit  of  $15  per  month,  one  a  minimum  benefit'  of  $20  per 
—30  H  I 


month  and  the  remainder  minimum  benefits  of  larger  amounts  ranging 
as  high  as  $25  per  week  (in  the  case  of  two  orders  whose  members  are 
largely  salaried  persons).  These  benefits,  it  should  be  stated,  are  for  the 
period  of  disability  during  which  full  benefits  are  paid;  as  will  be  ex- 
plained later,  they  are  frequently  scaled  down  after  a  certain  number  of 
weeks  and  months. 

Seventeen  of  the  32  socieites  under  discussion  reported  benefits 
which  vary  in  amount  in  accordance  with  the  dues  paid  by  the  insured 
member  or  in  accordance  with  this  factor  and  the  occupational  or  other 
classification  of  the  member.  One  society,  for  example,  oSers  benefits 
of  $4,  $6,  $8  or  $10  per  week;  another  offers  benefits  of  $5,  $7.50,  $10  or 
$15  per  week;  a  third,  benefits  of  $1,  $2,  or  $3  per  day;  and  a  fourth, 
benefits  varying  from  $15  to  $100  per  month. 

Twenty-nine  of  the  32  societies  reported  rules  requiring  a  mini- 
mum duration  of  disability  before  a  member  can  claim  sick  benefits. 
Three  societies  prescribe  a  "waiting  period^^  of  two  weeks;  one  society 
prescribes  a  waiting  period  of  eight  days;  one,  five  days,  and  one,  one 
day.  Another  prescribes  a  waiting  period  of  seven  days  for  certain 
classes  of  members  and  a  waiting  period  of  one  day  for  other  members. 
All  the  others  have  a  waiting  period  of  one  week.  The  insistence  upon 
a  moderate  waiting  period  makes  the  cost  of  the  sick  benefits  less  without 
working  severe  hardships  upon  the  members;  it  also  probably  reduces 
very  considerably  the  danger  of  simulation  for  this  reason  that  it  is 
more  difficult  to  simulate  illness  successfully  for  several  days  or  a  week 
than  for  a  day  or  two. 

Where  sick  benefits,  so-called,  are  paid  indiscriminately  for  loss  of 
time  whether  it  results  from  sickness  or  from  accidental  injuries,  the 
same  waiting  period  rule  naturally  applies  to  both  types  of  cases.  Where 
distinct  accident  benefits  are  paid  for  loss  of  time,  however,  the  benefits 
are  commonly  paid  from  the  day  of  the  accident. 

In  some  societies  sick  benefits  are  paid  for  the  waiting  period  if 
disability  lasts  beyond  the  waiting  period ;  in  others  they  are  not.  Ten 
of  the  32  societies  reported  that  they  pay  benefits  from  the  date  the  dis- 
ability begins  or  the  date  of  the  first  visit  of  the  attending  phj^sician,  one 
that  it  pays  from  the  date  the  disability  is  reported,  and  ten  that  they  pay 
from  the  end  of  the  waiting  period.  Two  of  the  32  societies  pay  no  loss  of 
time  benefits  until  the  disability  has  lasted  six  months  and  one  pays  no 
loss  of  time  benefits  until  the  disability  has  lasted  13  weeks.  In  all 
three  of  these  societies  the  constitution  and  by-laws  provide  that  the 
local  lodges  shall  pay  benefits  to  disabled  members  until  they  are  entitled 
to  receive  benefits  from  the  grand  lodge.  The  returns  from  the  remain- 
ing eight  societies  fail  to  disclose  the  practice  with  respect  to  the  pay- 
ment of  benefits  for  the  waiting  period. 

The  combination  of  local  and  centralized  administration  of  sick 
benefit  funds  by  the  three  societies  just  mentioned  is  a  fact  of  con- 
siderable significance  in  the  study  of  fraternal  health  and  accident  in- 
surance. One  of  the  dangers  of  the  plan  of  providing  benefits  entirely 
through  the  local  lodges  is  that  the  "law  of  the  averages,''  which  is  very 
important  in  insurance,  will  not  apply  because  of  insufficient  numbers  in 
the  average  local  lodge  and  that  consequently  individual  lodges  will  be 
overwhelmed  financially  by  the  burden  of  caring  for  cases  of  chronic 


467 

or  protracted  illness  ui*  accident  disability  or  that  these  cases  will  go 
uncared  for.  On  the  other  hand  one  of  the  dangers  of  the  plan  pro- 
viding disability  benefits  through  the  gi*and  lodge  is  found  in  the  diffi- 
culty of  detecting  cases  of  simulation  and  malingering  from  a  distance. 
The  combination  plan  used  by  the  three  societies  represents  an  attempt 
to  combine  the  broader  insurance  basis  afforded  by  the  carrying  of  the 
risks  in  the  grand  lodge  with  the  close  supervision  of  claimants  of  bene- 
fits which  is  possible  when  benefits  are  administered  by  the  local  lodges. 

Although  it  is  possible,  by  charging  enough  for  the  insurance,  to 
provide  for  the  continuous  payment  of  sick  benefits  for  a  sickness  of  any 
duration,  however  long,  none  of  the  32  societies  at  present  under  dis- 
cussion and  few  of  the  other  fraternal  societies  from  which  information 
was  received  attempt  to  do  this  except,  perhaps,  in  certain  cases  of 
permanent  and  total  disability.  The  table  on  the  next  page  shows  the  time 
limitations  imposed  by  37  of  the  32  societies  upon  the  payment  of  sick 
benefits.  The  remaining  five  societies  are  excluded  from  the  table  be- 
cause three^^  pay  accident  benefits  only  and  the  other  two  failed  to  report 
definitely  the  time  limitations  on  their  benefits. 

In  most  of  the  societies  shown  in  the  table  disability  from  acci- 
dental injuries  is  reated  as  a  form  of  sickness  and  is  indemnified  by 
the  ordinary  sick  benefit  for  loss  of  time.  In  some  of  these  societies, 
however,  there  are  specific  benefits  for  specific  injuries  or  losses  and  in 
a  number  the  loss  of  time  resulting  from  disability  caused  by  accidental 
injuries  is  indemnified  by  a  special  accident  benefit  which  differs  from 
the  sick  benefit.  The  benefits  for  specific  injuries  and  losses  are  dicussed 
in  a  later  section  of  this  study.  Five  of  the  societies  provide  indemnities 
for  loss  of  time  from  accidental  injuries  which  differ  from  those  which 
they  provide  for  loss  of  time  from  sickness.  In  four,  the  accident  bene- 
fit may  be  paid  for  a  longer  period  of  time  than  the  sick  benefit ;  in  one, 
this  relation  of  the  time  limit  is  reversed. 

The  rates  of  benefit  paid  for  disability  from  sickness  and  disability 
from  accidental  injuries  differ  in  two  of  the  societies.  One  society  pays 
benefits  ranging  from  $7  to  $20  per  week  for  total  disability  from  acci- 
dental injuries  and  40  per  cent  of  these  benefits  for  partial  disability 
from  accidental  injuries,  while  it  pays  benefits  ranging  from  $8  to  $15 
per  week  for  total  and  confining  disability  from  sickness  and  one-fifth 
of  these  benefits  for  partial  disability  from  sickness.  The  other  society 
pays  sick  benefits  ranging  from  $10  to  $120  per  month  and  accident 
benefits  ranging  from  $20  to  $80  per  month. 

The  conditions  under  which  members  of  the  fraternal  societies 
which  pay  sick  and  accident  benefits  through  the  grand  lodges  may  be 
insured  for  these  benefits  vary  so  greatly  that  it  is  impossible  to  state  a 
general  rule.*°  Twenty-three  of  the  32  orders  receive  both  men  and 
women  as  members.     Two  of  the  23  report  the  exclusion  of  women  from 

**  Two  of  these  three  orders  are  composed  chiefly  of  traveling  salesmen  and  have, 
therefore,  practically  no  wage-earners  among  their  members,  in  the  sense  in  which 
the  term  "wage-earner"  is  used  in  this  report.  The-  other  order  is  composed  of  em- 
ployees in  the  United  States  railway  mail  service  and  may  properly  be  called  an 
association  of  wage-earners,  although  its  members  are  more  highly  paid  than  most 
of  the  wage-earners  with  whom  the  investigation  of  the  Commission  has  been  con- 
cerned. This  society  reports  that  it  pays  benefits  of  $21  per  week  for  a  maximum 
period  of  52  weeks  in  case  of  disability  from  accidental  injuries. 

*°  The  conditions  governing  admission  to  membership  in  fraternal  societies  are 
discussed  on  page  449  above. 


468 

participation  in  the  sick  or  accident  benefit  plans.  One  of  these  reports 
that  women  are  insured  for  death  benefits  only,  the  other  that  the  wives 
of  members  are  excluded  from  participation  in  the  sick  and  accident 
benefits.  The  total  number  of  females  in  the  two  orders  in  Illinois  on 
December  31,  1917,  was  515.  Of  the  nine  orders  which  do  not  admit 
both  sexes  to  membership,  one  is  for  women  only,  and  eight  are  for  men 
only. 


Maximum  continuous 
period  for  which 

benefits  may  be  paid 
by  grand  lodge. 


Number 

of 
societies. 


Amount  of  benefit  per 
week. 


Remarks. 


5  years,  6  months 
2  years 


1  year,  28  weeks.. 
1  year,  6  months. , 


lyear. 
1  year. 
1  year. 
1  year. 


50  weeks. 


10  months. 


40  weeks . . 

30  weeks.. 

6  months. 


6  months. 

6  months. 

6  months. 

6  months. 
24  weeks . . 
16||weeks.. 
15  weeks.. 
15  weeks.. 


12  weeks. 

12  weeks. 
12  weeks. 
10  weeks. 
10  weeks. 


$  5.00 

6.00 

6. 00  or  $9. 00. 
5.00 

"3'56toVl4.0b 
7. 00  to  $21. 00 
7. 00  or  $14. 00 

4. 00  to  $10. 00 


10. 00  to  $120.00  per  month 


10.00 

6.00 

20. 00  per  month. 


5. 00  to  $25. 00 

5. 00  to  $20. 00 

5. 00  to  $15. 00 

15. 00  to  $100.00  per  month 

6. 00  to  $12. 00 

5.00  or  $7.00 

5. 00  or  $10. 00 

5.00 


8. 00  to  $15. 00. 

5. 00  to  $15. 00. 

6.00 

2. 50  to  $10. 00. 
5.00 


No  reduction  in  benefit. 

No  reduction  in  benefit.     Grand  lodge 

begins  payment  after  local  lodge  has 

paid  for  3  months. 
Benefit  reduced  to  one-half  after  40  weeks. 
No  reduction  in  benefit.     Grand  lodge 

begins  payment  after  local  lodge  has 

paid  for  6  months. 
Data  regarding  benefits  incomplete. 
Benefit  reduced  to  one-half  after  6  months. 
Benefit  reduced  to  one-half  after  6  months. 
Benefit  reduced  to  $20.00  or  $40.00  per 

month  after  6  months. 
Ten  year  benefit  certificate  entitles  holder 

to  5  weeks'  benefits  per  year.    Benefit 

undrawn  in  one  year  may  be  drawn  in 

any  subsequent  year,  hence  the  maxi- 
mum stated. 
Eight  months  for  total  and  confining  dls- 

abihty,  2  months  for  partial  disability. 
Benefit  reduced  to  one-half  after  26  weeks. 
Benefit  reduced  to  one-half  after  15  weeks. 
No  reduction  in  benefit.     Grand  lodge 

begins  payment  after  local  lodge  has 

paid  for  6  months. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 
Benefit  reduced  to  one-half  after  12  weeks. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 
Benefit  reduced  to  S3.00  at  end  of  fifth 

week  and  to  S2.00  at  efld  of  tenth  week. 
If  disability  partial,  benefits  are  one-fifth 

those  stated. 
Data  regarding  benefits  incomplete. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 
No  reduction  in  benefit. 


Twenty-eight  of  the  32  societies  report  that  the  age  qualifications  for 
admission  to  participation  in  sick  and  accident  benefits  do  not  differ 
from  those  for  admission  to  participation  in  death  benefits.  Thirteen 
of  the  28  have  a  minimum  age  qualification  of  16  years  for  beneficiary 
members;  one  prescribes  17  years  as  the  minimum;  and  14  place  the 
minimum  at  18  years.  The  maximum  age  reported  as  qualifying  an 
applicant  for  tnitmtion  into  a  society  ranges  for  the  28  societies  from  45 
to  60  years;  ten  societies  report  50  years  as  the  maximum;  six,  60 
years;  five,  45  years;  five,  55  years;  one,  54  years;  and  one,  59  years. 
Ihe  maximum  age  for  initiation,  however,  is  not  necessarily  the  maxi- 
mum age  at  which  members  of  an  order  in  which  sick  "benefits  are 
optional  may  insure  against  sickness  nor  the  age  at  which  sick  benefits 
purchased  at  an  earlier  age  must  cease.    A  study  of  the  constitutions 


469 

and  by-laws  of  a  number  of  the  societies  under  discussion  indicates  that 
at  least  a  considerable  proportion  of  them  place  no  maximum  age  limit 
on  the  carrying  of  sick  benefits;  the  failure  of  other  societies  to  provide 
the  Commission  with  copies  of  their  constitutions  and  by-laws  makes  it 
impossible  to  make  a  more  general  statement  of  the  practice  of  the 
societies  in  this  respect. 

Two  of  the  four  remaining  societies  which  reported  that  they 
furnish  sick  or  accident  benefits  through  the  grand  lodge  have  special 
age  limits  for  these  benefits.  In  one  of  them  persons  between  the  ages 
of  16  and  60  are  admitted  to  beneficiary  membership  in  the  order  but 
male  members  who  are  55  years  of  age  or  more  and  female  members  who 
are  40  years  of  age  or  more  are  ineligible  to  become  "relief  members/'  as 
the  members  who  participate  in  sick  and  accident  benefits  are  called. 
In  the  other  society  the  age  limits  for  entrance  to  the  order  as  a  bene- 
ficiary member  are  also  16  and  60  but  members  under  18  and  over  45 
years  are  not  eligible  for  admission  to  participation  in  the  sick  and  acci- 
dent benefits  plan.  In  the  first  society  membership  in  the  "relief  depart- 
ment" terminates  automatically  for  male  members  when  they  reach  the 
age  of  60  years  and  for  female  members  when  they  reach  the  age  of  50 
years.  In  one  of  the  28  societies  mentioned  previously  the  right  of  mem- 
bers to  receive  sick  benefits  ceases  when  they  attain  the  age  of  60  years,, 
which  is  the  maximum  age  for  admission  to  the  society.  Two  societies 
failed  to  report  the  age  qualifications  for  participation  in  their  sick  bene- 
fit funds. 

In  a  few  societies  members  of  the  older  ages  are  permitted  to  partici- 
pate in  sick  benefits  but  are  limited  to  the  smallest  benefits  provided.  In 
one  society,  for  example,  "every  male  and  female  member  may  insure 
himself  or  herself  up  to  the  age  of  45  years  for  either  $1  or  $2  sick  benefit 
a  day"  but  "members  who  are  over  45  years  of  age  can  insure  themselves 
for  $1  sick  benefit  a  day  only."  Another  society  which  provides  sick 
benefits  of  $3.50,  $7  and  $14  per  week  restricts  "persons  between  45  and 
50  years  of  age"  to  the  "lowest  class  of  sick  benefits." 

As  a  rule  the  occupational  restrictions  which  govern  admission  to 
the  sick  and  accident  benefit  funds  of  the  societies  which  administer  these 
funds  through  the  grand  lodges  are  stated  in  the  requirements  for  ad- 
mission to  the  order  as  a  beneficiary  member  (that  is,  as  a  member  carry- 
ing life  insurance  in  the  order).  The  general  nature  of  these  require- 
ments has  been  described  on  a  previous  page.*^ 

All  of  the  32  orders  under  discussion  require  medical  examinations 
of  the  applicants  for  admission  to  the  sick  and  accident  benefit  funds, 
but  in  most,  if  not  all,  of  these  orders  the  examination  given  for  life 
insurance  in  the  order  is  accepted  as  sufficient  for  these  other  forms  of 
insurance.  The  practice  usually  followed  by  those  orders  in  which  mem- 
bership in  the  sick  or  accident  benefit  department  is  optional  with  the 
members  of  the  order  when  the  latter  apply  for  sickness  or  accident 
benefits  some  years  after  having  been  examined  for  life  insurance  is  not 
clear  from  the  data  presented  to  the  Commission.  It  appears,  however, 
that  at  last  come  of  these  orders  require  a  new  medical  examination. 

*i  Page   449.   above. 


470 


Like  the  health  insurance  written  by  the  casualty  companies/^  the 
sick  benefits  provided  by  the  fraternal  orders  do  not  cover  all  forms  of 
sickness.  Venereal  diseases,  diseases  resulting  from  the  intemperate  use 
of  alcoholic  liquors  or  narcotics,  diseases  not  common  to  both  sexes,  and 
diseases  resulting  from  unnecessary  exposure  are  the  diseases  most  com- 
monly excluded  from  coverage.  In  some  societies  reduced  benefits  or  no 
benefits  at  all  are  paid  for  certain  chronic  or  other  diseases  such  as  "rheu- 
matism, neuralgia,  lumbago,  varicose  veins,  chronic  hermorrhoids,  fistula, 
hernia,  nervous  prostration,  fits,  crick,  gout,"  to  quote  from  a  rather  full 
list  published  in  the  constitution  of  one  order.  Some  societies  with 
women  members  pay  benefits  for  disability  resulting  from  pregnancy  and 
child-birth,  others  do  not;  the  practice  of  the  societies  with  respect  to 
maternity  benefits  will  be  discussed  in  a  subsequent  section.^^ 

Thirty-nine  societies,  including  some  of  those  which  have  been  dis- 
cussed in  the  foregoing  pages  and  some  of  those  which  have  been 
mentioned,  reported  to  the  Commission  that  they  make  provision  for  the 
payment  of  specific  injury  benefits  through  their  grand  lodges.  These 
societies  had  an  aggregate  membership  of  255,881  persons  on  December 
31,  1917.  This  membership  is  confined  to  no  racial,  religious  or  occu- 
,  pational  gi'oup  but  is  broadly  representative  of  the  various  groups  which 
make  up  the  fraternal  life  insurance  world. 

There  are  no  doubt  a  variety  of  reasons  which  have  influenced  the 
societies  mentioned  to  make  provision  for  specific  injury  indemnities.  In 
some  societies  the  members  are  exposed  to  peculiar  hazards  of  occupation ; 
this  is  true  of  a  nmnber  of  societies  whose  membership  is  not  confined  to 
persons  engaged  in  the  same  occupation  as,  for  example,  one  order  which 
reports  a  large  number  of  miners  among  its  members,  and  another  which 
is  composed  largely  of  farmers.  In  other  societies  specific  injury  in- 
demnities appear  to  have  been  adopted  in  recognition  of  their  value  to  the 
membership  in  general— for  insurance  of  this  kind  is  desirable  if  not 
too  costly— or  as  a  competitive  device  for  use  in  attracting  and  holding 
members. 

The  time  and  space  available  for  the  preparation  and  publication  of 
this  study  do  not  permit  a  detailed  description  of  the  character  of  the 
specific  injury  indemnities  offered  the  public  by- the  fraternal  societies 
operating  in  Illinois  nor  the  presentartion  of  statistics  showing  the  amount 
of  this  insurance  which  is  carried  by  wage-earners  in  the  State.  It 
must  suffice  to  say  that  the  specific  injuries  covered  vary  more  or  less 
^^°??/°^^®^y  to  society;  that  they  include  in  the  aggregate  not  only  loss 
i!:^'  T^  '  ^^^^'^  ^''  h^^^g  fi"^^  accidental  injuries,  but  also  loss  of 
sight  or  hearing  and  paralysis  resulting  from  disease  and  insanity;  and 
that  the  policies  or  certificates  used  and  the  by-laws  which  govern  the 
indemnity  contract  seem  to  have  been  considerably  influenced  by  the  con- 
tracts used  by  the  casualty  companies.     Reference  may  be  made  in 

support  of  this  statement  to  the  schedule  of  benefits  shown  on  pa^e of 

this  study.     When  specific  injury  benefits  are  paid  for  losses  or  injuries 
resulting  either  from  sickness  or  from  accidental  injuries  the  society 

*'8ee  pp.  407,  Part  II,  Special  Report  VI 
« Pages  478.  480  below.  p     «-   vi. 


471 

is  usually  relieved  of  the  necessity  of  paying  disability  benefits  in  the 
same  case  for  loss  of  time.  This,  it  will  be  remembered,  is  in  accord- 
ance with  the  practice  of  the  casualty  companies.''* 

Only  a  few  of  the  societies  which  provide  sick  and  accident  benefits 
through  the  grand  lodges  attempt  to  furnish  medical  treatment  for  mem- 
bers except  as  a  matter  of  charity,  either  before  or  during  disability;  in 
most  of  these  societies  the  choice  and  payment  of  a  physician  are  left 
entirely  to  the  individual  member.  Two  societies  report  that  they 
furnish  medical  treatment  to  all  members  needing  it.  A  study  of  the 
constitution  and  bv-laws  of  one  of  these  societies  indicates,  however, 
that  the  functions  of  the  society  physicians  in  this  order,  one  or  two  of 
whom  are  elected  by  each  local  lodge,  are  largely  to  investigate  claims 
for  the  society  and  check  malingering  and  simulation;  when  a  member 
requestes  the  services  of  the  physician  elected  by  his  local  lodge  the  fees  for 
these  services  are  assessed  against  him  as  a  special  charge.  Seven  other 
societies  report  that  the  provision  of  medical  treatment  is  left  to  the 
local  lodges;  in  one  of  these  societies  some  of  the  local  lodges  levy  an 
assessment  of  25  cents  per  month  to  pay  for  medical  treatment;  in 
another  some  of  the  local  lodges  provide  medical  and  surgical  treatment 
for  members  who  have  sustained  accidental  injuries,  although  the  society 
reports  that  similar  provision  is  not  made  in  cases  of  sickness.^^  In 
some  of  the  societies  under  discussion  specific  benefits  are  paid  to  cover 
costs  of  surgical  operations. 

The  foregoing  pages  have  revealed  the  fact  that  the  health  and 
accident  contracts''^  used  by  the  fraternal  societies  which  furnish  health 
and  accident  insurance  through  the  grand  lodges  are  of  great  variety. 
Because  of  this  situation  it  is  hardly  possible  to  sepak  of  typical  con- 
tracts or  to  compare  their  cost  with  the  cost  of  similiar  contracts  written 
by  the  casualty  companies.  The  claims  made  for  the  superior  economy 
with  which  the  fraternal  orders  assert  that  they  conduct  the  business  of 
life  insurance  have  already  been  noted  ;*^  in  so  far  as  these  claims  may 
be  valid  they  apply  about  equally  well  to  the  health  and  accident  in- 
surance business  as  conducted  by  the  grand  lodges  of  fraternal  orders. 

Although  there  are  no  contracts  which  are  thoroughly  typical  of  all 
or  even  of  most  of  the  contracts  used  by  the  fraternal  societies  which  write 
health  and  accident  insurance  through  their  grand  lodges  the  following 
schedule  of  benefits  and  charges  may  have  illustrative  value.  This 
schedule  is  used  by  one  of  the  larger  societies  which  issues  a  contract 
similar  in  some  respects  to  the  contracts  used  by  casualty  companies. 

"Upon  the  furnishing  of  satisfactory  proof,  this  Society  agrees  to  pay 
benefits  under  this  certificate,  according  to  its  grade  and  the  Class  of  the 

**  See  Special  Report  VI,  pp.    415. 

*°  It  is  possible  that  the  provision  of  medical  or  surgical  treatment  in  some  of 
the  societies  referred  to  here  is  made  as  a  matter  of  charity  rather  than  in  com- 
pliance with  an  insurance  agreement. 

^•^  Some  of  the  societies  to  which  reference  is  made  furnish  their  members  with 
special  certificates  containing  the  agreement  with  respect  to  sick  and  accident  bene- 
fits ;  others  add  special  clauses  governing  these  benefits  to  the  life  crtiflcates ;  some 
appear  to  furnish  no  written  evidence  of  the  contract  except  that  contained  in  the 
constitution  and  by-laws  of  the  society. 

*^  Pages  453  above. 


472 


occupation  in  which  tlie  member  is  engaged,  as  indicated  in  the  column 
marked  with  an^X  in  the  following  table. 


Disability. 


First  grade. 


Preferred. 


Ordinary. 


Medium. 


Second  grade. 


Preferred.  Ordinary 


Medium. 


.  Accidental  death  or  loss  of  two  limbs 
or  both  eyes 

2.  Loss  of  hand,  foot  or  eye 

3.  Total    disability    from    accident, 

weekly  benefit 

4.  Partial    disability    from    accident, 

weekly  benefit 

5.  Funeral  benefit 

6.  Totaldisabiliiy  from  sickness,  weekly 

benefit,  after  first  week 

7.  Partial    disability    from    sickness, 

weekly  benefit,  after  first  week. 

8  Total  disability  from  sickness,  bene- 
fit first  week 

9.  Partial  disability  from  sickness,  bene- 
fit, fijTst  week 


5 

S600.00 
300.00 

$450.00 
225.00 

$300.  OO' 
150.00 

$400.00 
200.00 

$300.00 
150.00 

20.00 

15.00 

10.00 

15.00 

10.00 

9.00 
100.00 

6.00 
100.00 

4.00 
100.00 

6.00 
100.00 

4.00 
100.00 

15.00 

15.00 

12.00 

10.00 

10.00 

3.00 

3.00 

2.40 

2.00 

2.00 

7.50 

7.50 

6.00 

5.00 

5.00 

1.50 

1.50 

1.20 

1.00 

1.00 

1 

$200.00 
100.00 

7.00 

2.80 
100.00 

8.00 

1.60 

4.00 

.80 


"Double  Benefits.  Above  benefits  under  (1),  (2),  (3),  and  (4), 
axe  doubled  if  the  injuries  are  sustained  while  the  member  is  riding  as  a 
passenger  on  a  passenger  train  propelled  by  steam  or  electricity,  and 
inside  a  coach  or  passenger  car  thereof,  or  by  the  burning  of  a  hotel,  public 
hall  or  theatre  while  the  member  is  stopping  at  such  hotel  as  a  guest  or 
while  in  attendance  at  a  public  meeting  or  performance  in  such  hall  or 
theatre  other  than  as  an  employee. 

"Age  at  Entry.  Above  benefits  are  payable  when  entry  age  is  be- 
tween 16  and  50.  Sixty  per  cent  only  of  the  above  benefits  under  (5), 
(6),  (7),  (8),  and  (9),  are  payable  when  entry  age  is  between  50  and  55.'' 

The  constitution  of  this  society  provides  that  the  certificates  shall 
be  divided,  as  indicated  in  the  schedule,  into  two  grades  and  that  the  rates 
shall  be  $1.50  per  month  for  certificates  of  the  first  grade  and  $1  per 
month  for  certificates  of  the  second  grade.  The  classification  of  risks 
into  "preferred,  ordinary  and  medium"  is  based  upon,  occupational 
hazards  and  adjustment  is  made  for  age  differences  by  reducing  certain 
of  the  benefits,  as  stated  in  the  schedule,  to  60  per  cent  of  the  amounts 
shown.  The  payment  of  sick  benefits  is  limited,  for  both  total  and  partial 
disability,  to  12  weeks  in  any  one  year  and  the  payment  of  accident 
benefits  for  total  and  partial  disability  to  26  weeks  in  any  one  year.  All 
certificates  held  by  male  members  terminates  at  age  60  and  all  certifi- 
cates lield  by  femaJe  members  terminate  at  age  50  "unless  sooner  ter- 
minated by  lapsation,  cancellation  or  otherwise." 

In  considering  the  rates  shown  in  the  above  schedule  it  should  be 
remembered  that  they  pay  not  only  for  sick  and  accident  benefits  for  loss 
of  time  but  also  for  accidental  death,  specific  injury  and  funeral  benefits. 
It  should  also  be  remembered  that  this  contract  is  more  important  as  an 
illustration  of  the  possibilities  of  fraternal  insurance  than  as  a  typical 
fraternal  contract.  Many  of  the  contracts  used  by  the  fraternal  societies 
have  a  more  limited  coverage  and  differ  in  other  respects  which  are  too 
numerous  to  describe  in  detail. 


473 

(4)  Sick  and  accident  benefits  provided  hy  the  local  lodges  in  so- 
cieties in  which  such  provision  is  compulsory. — The  reports  of  the  Super- 
intendent of  Insurance  show  only  those  sick  and  accident  claims  which  are 
paid  by  the  grand  lodges  of  the  fraternal  societies.  In  discussing  the  sick 
and  accident  benefits  provided  by  the  local  lodges  it  is  therefore  necessary 
to  rely  upon  data  gathered  directly  by  the  Commission.  As  indicated  in 
the  tables  given  above/^  information  was  secured  from  21  fraternal 
societies  operating  in  Illinois  which  make  the  provision  of  sick  benefits 
compulsory  upon  the  local  lodges.  Of  these  societies  17  were  life  in- 
surance orders  with  a  total  beneficiary  membership  56,797  on  Decem- 
ber 31,  1917,  and  four  were  orders  which  do  not  provide  life  insurance, 
with  a  total  membership  in  1918  of  146,752. 

Estimates  made  by  the  grand  secretaries  of  the  17  life  insurance 
orders  indicate  that  fully  45,000  of  the  56,797  members  of  these  orders 
should  be  classed  as  members  of  the  wage-earning  class.  This  conclusion 
is  supported  by  the  fact  that  13  of  the  societies  are  composed  chiefly  of 
immigrants  or  native-born  persons  of  immigranl:  parentage,  and  three 
of  negroes. 

Similar  estimates  are  available  for  only  two  of  the  four  non-life-in- 
surance orders  comprising  but  one-seventh  of  the  total  meilibership  of 
the  four  and  it  is  therefore  impossible  to  arrive  at  a  definite  conclusion 
as  to  the  proportion  of  wage-earners  among  the  total  membership  of 
these  orders.  In  the  light  of  such  information  and  such  estimates  as 
are  available,  however,  it  does  not  appear  unreasonable  to  assume  that 
the  total  number  of  wage-earners  among  the  members  of  the  four  orders 
is  between  75,000  and  100,000. 

Some  of  the  members  of  some  of  the  societies  under  discussion 
probably  do  not  participate  in  the  sick  benefit  plans  adopted  by  the  local 
lodges  but  the  data  available  to  the  Commission  do  not  permit  a  statement 
of  the  number  of  such  members  or  of  the  rules  governing  participation 
in  the  benefits. 

It  is  also  impossible  to  state  the  total  amount  of  the  sick  benefits 
paid  during  1917,  or  any  other  year,  by  the  local  lodges  of  the  21  societies. 
In  some  of  the  societies  no  reports  of  the  benefits  paid  are  made  to  the 
grand  secretary.  Other  societies  for  one  reason  or  another  failed  to 
furnish  the  Commission  with  all  of  the  information  requested.  Definite 
information  concerning  the  amount  of  the  sick  benefits  paid  in  1917  is 
available,  however,  for  4  of  the  21  orders,  including  the  largest  one  of  all, 
with  an  aggregate  membership  of  123,773,  or  60.9  per  cent  of  the  203,549 
members  of  the  21  orders  which  reported  that  the  payment  of  sick  bene- 
fits was  compulsory  upon  the  local  lodges.  These  4  societies  paid  a 
total  of  $190,227.18  in  sick  benefits  in  the  year  1917.  About  94  per 
cent  of  this  amount  was  paid  by  the  society  to  which  reference  has  just 
been  made.  The  following  table,  compiled  from  data  furnished  by 
the  secretary  of  the  Grand  Lodge  of  Illinois,  shows  the  experience  of  this 
society  in  the  payment  of  sick  benefits  in  Illinois  during  the  year 
mentioned. 


*8  Pages  465-465. 


474  ^^^^^^^^^ 

lodges  in  Illinois,  Jan.  1,  1918 ^^^^^^^^^^i  n «  q?  I 

.Jtembcrs  in  Illinois,  Jan.  1,  1918..  .-••• tIJS 

Members  receiving  sick  benefits  in  1917 :  •  •  ■  j  '  2'  "  i-"  '   -  '  y  '  li.  <,<3t 

Amount  paid   in   sick   benefits   in   1917    (exclusive   of   donations,    death 

benefits  and  other  relief  necessitated  by  sickness. $178,bU7.51 

Average  amount  of  sick  benefits  received  by  each  sick  member 47*~i 

Average  duration  of  sickness a   aays 

Average  cost  per  member  to  pay  sick  benefits   (exclusive  of  donations, 

death  benefits  and  other  relief) ^i.K)i) 

In  explanation  of  the  data  shown  in  the  table  it  should  be  stated 
that  the  local  lodges  of  this  society  in  Illinois  are  required  to  pay  sick 
benefits  of  not  less  than  $2  per  week  and  are  permitted  to  pay  sick  bene- 
fits as  much  larger  as  they  care  to  provide  for  in  their  by-laws.  It  is 
apparent  from  the  average  amount  of  sick  benefits  received  per  sick 
member  and  the  average  duration  of  sickness  that  the  average  weekly 
sick  benefit  paid  by  the  local  lodges  of  the  order  exceeds  the  minimum  of 
$2.  The  secretary  of  the  grand  lidge  for  Illinois  advises  the  Commission 
that  "possibly  the  average  rate  of  sick  benefits  in  Illinois  would  be  about 
$3  per  week"  but  states  that  "many  lodges  pay  as  high  as  $5  per  week." 
The  local  lodges  are  required  to  pay  sick  benefits  continuously  as  long  as 
a  sick  member  is  disabled,  unless  he  is  admitted  to  the  home  maintained 
by  the  order,  "but  the  rate  may  be  changed  by  by-law." 

More  Or  less  detailed  information  concerning  the  nature  of  the 
sick  benefits  paid  by  the  local  lodges  was  obtained  from  17  of  the  other 
20  orders  which  reported  the  provision  of  sick  benefits  as  being  com- 
pulsory upon  the  local  lodges.  This  information  is  presented  in  part  in 
the  following  table,  numbers  being  substituted  for  the  names  of  the 
several  orders. 


Society  number. 


Sick  benefits,  amount  and  limitations.* 


Dues  for  sick  benefits. 


1 
2 

3 

4 
5 

6 

7 

8 
9 

10 

11 
12 
13 
14 
16 
16 
17 


Not  less  than  $5  required 

12  per  week  for  6  months,  $1  per  week  for  6  months  more; 

$78  maximum  for  life 

$5-$12;  most  lodges  pay  J6;  a  few,  $7;  13-18  weeks  per 

year 

$5-$7;  15-26  weeks  per  year 

$5  for  13  weeks;  $2.50  for  13  weeks;  not  more  than  26  weeks 

in  3  years 

$5  the  minimum;  lodges  often  pay  $6  or  $7  or  for  member 

in  hospital,  $10.    Limit  6  monthsf 

$5  per  week,  or  more  than  6  months,  after  which  local 

lodge  may  continue  benefit  $20  or  $10  per  month  if 

funds  warrant 

$4-$5  for  6-12  weeks  per  year 

$l-$5;  most  lodges  pay  about  $5;  some  reduce  from  $5  to 

$2.50  after  13  weeks 

Men  $3,  women  $2.50  for  5  weeks,  then  at  half  rates  "  and 

the  order  keeps  up  the  dues  of  sick  member" 

$5  for  25  weeks 

Not  more  than  $5  for  not  more  than  13  weeks  per  year. . 

Usually  $5-$7  for  13  weeks  per  year 

Not  less  than  $2  required 

$5  for  13  weekst 

Average  $1  per  day " ." 

Not  less  than  $2  required 


No  report. 

50c  quarter. 

50c-$l  month. 
50c  month. 

50c  month. 

50c-75c  month. 


No  report. 
25c-35c  month. 

No  report. 

No  report. 

50c  month. 

No  report. 

Usually  50c-70c  month. 

No  report. 

Vary  as  needed. 

Average  $75c-81  month. 

25c  month  and  up. 


•  Unless  otherwise  indicated  the  rate  shov^m  is  the  rate  per  week, 
t  After  the  local  lodge  has  paid  benefits  for  the  maximum  period  indicated  the 
grand  lodge  pays  such  further  benefits  as  may  be  payable  to  the  sick  member. 

The  above  table  ilustrates  the  lack  of  standardization  which  is 
characteristic  of  the  sick  benefits  provided  by  the  fraternal  societies. 
It  also  illustrates  the  inadequacy  of  the  benefits  provided  by  the  local 


475 

lodges  for  it  is  obvious  that  benefits  averaging  not  more  than  $5  or  $6 
per  week  and  limited  in  most  cases  to  13  weeks  or  6  months  of  sickness 
are  inadequate.*^  It  should  be  said^  however,  that  some  wage-earners 
are  members  of  several  fraternal  societies  and  are  thus  able  to  secure 
protection  which  is  more  nearly  adequate  in  amount  per  week  or  month 
if  not  in  the  number  of  weeks  or  months  for  w^hich  it  may  be  paid.  In 
fact  evidence  has  come  to  the  attention  of  the  Commission  which  indicates 
that  a  few  wage-earners  are  actually  over-insured  against  sickness  in  as- 
much  as  the  aggregate  amount  of  weekly  or  monthly  indemnity  pay- 
able to  them  by  fraternal  societies,  and,  possibly,  casualty  companies 
or  other  carriers,  in  case  of  sickness  exceeds  the  amount  of  their  weekly 
earnings.  But  such  cases  are  rare  and  it  is  safe  to  say  that  the  majority 
of  wage-earners  who  carry  sick  benefits  in  the  local  lodges  of  the  fraternal 
orders  under  discussion  have  insufficient  protection  in  respect  both  to  the 
amount  of  the  weekly  or  monthly  indemnity  and  the  length  of  time  for 
which  it  is  payable. 

The  explanation  of  the  inadequacy  of  these  benefits*^  appears  to  lie 
largely  in  the  cost  of  the  insurance.  Adequate  protection  in  these 
societies  would  cost  the  average  wage-earner  more  than  he  is  able  or 
willing  to  spend  for  health  insurance.  This  is  not  io  say  that  the  rates 
charged  by  the  local  lodges  are  excessive,  for  the  sick  benefits  are  managed 
by  the  lodges  on  a  cooperative  basis  and  the  members,  in  the  absence  of 
dishonest  or  inefficient  management,  get  what  they  pay  for.  The  diffi- 
culty is  one  which  appears  to  be  fundamental  in  all  forms  of  voluntary 
health  insurance  now  in'  operation  in  the  United  States. 

In  most  of  the  21  societies  under  discussion  the  sick  benefits  provided 
by  the  local  lodges  cover  loss  of  time  from  disability  resulting  from  acci- 
dental injuries  in  precisely  the  same  way  as  they  cover  loss  of  time  result- 
ing from  disability  from  sickness.  In  three  societies  the  grand  lodges 
make  provisions  for  the  payment  of  specific  accident  indemnities,  and 
when  such  benefits  are  paid  they  are  commonly  paid  in  lieu  of  all  other 
benefits.  But  in  these  three  societies  cases  of  accidental  injuries  which 
are  not  of  such  a  character  as  to  require  the  payment  of  specific  accident 
indemnities  are  treated  as  cases  of  sickness. 

Data  with  respect  to  the  waiting  period  were  submitted  by  five  of 
the  21  societies.  Two  reported  a  waiting  period  of  one  week  in  all  lodges, 
one  a  waiting  period  of  two  weeks  in  all  lodges,  one  a  waiting  period  of 
one  week  in  some  lodges  and  a  waiting  period  of  two  weeks  in  others, 
and  one  reported  that  the  local  lodges  had  no  waiting  period.  In  two 
of  the  societies  in  which  a  waiting  period  was  required  sick  benefits, 
when  payable,  were  payable  from  the  first  day  of  sickness ;  this  was  true 
in  some  of  the  lodges  in  a  third  order  but  not  in  all  of  them.  In- 
formation is  not  available  concerning  this  detail  for  the  fourth  order 
which  reported  the  requirement  of  a  waiting  period. 

*'  The  characterization  of  the  benefits  under  discussion  as  inadequate  is  not  in- 
tended to  reflect  in  any  way  on  the  societies  which  provide  them.  These  societies 
in  fact  deserve  great  credit  for  having  done  as  much  as  they  have  to  meet  the 
needs  of  their  members  for  health  insurance. 


476 

Infoi-mation  concerning  age  qualifications  for  membership  were  re- 
ceived from  19  of  the  21  orders  under  discussion.  The  minimum  age 
qualifications  range  from  16  to  21,  with  seven^^  societies  reporting  16 
years,  and  ten,  18  years,  as  the  minimum.  The  maximum  age  quali- 
fications range  from  45  to  55,  with  seven  societies  reporting  45,  seven, 
60,  and  three,  55  years  as  the  maximum.  These  qualifications,  it  should 
be  emphasized,  are  for  original  admission  to  the  societies.  They  do  not 
necessarily  govern  admission  to  the  sick  funds  but  what  the  actual 
practice  of  the  societies  is  in  this  respect  the  information  available  does 

not  disclose. 

Two  societies  reported  that  the  local  lodges  provide  medical  care  for 
sick  members  at  an  expense  per  member  of,  respectively,  $1  and  $1.50 
per  year.  Another  society  reported  that  the  local  lodges  provide  hospital 
service,  when  necessary,  for  sick  members.  A  fourth  society  stated  that 
most  of  the  local  lodges  have  "lodge  physicians"  who  are  usually  com- 
pensated at  the  rate  of  $1  or  $2  per  member  per  year. 

(5)  Sich  and  accident  benefits  provided  by  the  local  lodges  in  so- 
cieties in  which  such  provision  is  optional  with  the  local  lodges. — Infor- 
mation was  obtained  from  56  fraternal  societies  operating  in  Illinois 
which  leave  the  provision  of  sick  benefits  optional  with  the  local  lodges. 
Of  these  52  were  life  insurance  orders  with  a  total  beneficiary  member- 
ship of  686,762  in  Illinois  on  December  31,  1917,  and  4  were  orders 
which  do  not  provide  life  insurance,  with  a  total  membership  in  the  State 
in  1918  of  55,791. 

The  information  which  the  Commission  has  with  respect  to  the  total 
number  of  persons  who  carry  sick  benefits  with  the  local  lodges  of  these 
societies,  the  proportion  who  are  members  of  the  wage-earning  class,  and 
the  aggregate  amount  of  sick  benefits  paid  in  a  year  through  these  local 
lodges  is  so  incomplete  that  it  is  impossible  to  present  reliable  statistics 
bearing  upon  them.  The  Commission  found  it  impossible  to  get  com- 
plete information.  In  only  a  few  cases  did  the  secretaries  of  the  grand 
lodges  have  the  data  desired,  for,  as  most  of  them  explained,  in  most 
societies  what  the  local  lodges  do  in  providing  optional  sick  benefits  is 
no  concern  of  the  grand  lodge.  It  was  therefore  necessary  to  ask  the 
secretaries  of  the  local  lodges  for  information.  Because  of  the  large 
number  of  local  lodges  in  Illinois  which  might,  under  the  laws  of  their 
societies,  provide  sick  benefits  if  they  so  wished,  it  was  necessary  to 
request  this  information  through  coiTespondence.  The  Commission  ac- 
cordingly prepared  a  questionnaire  which  it  sent  with  the  cooperation 
of  the  secretaries  of  the  grand  lodges,  to  the  secretaries  of  about  4,900 
local  lodges  in  various  orders  operating  in  Illinois.,  Satisfactory  or 
serviceable  replies  were  received  from  1,871  of  the  local  lodges  repre- 
senting 35  fraternal  orders  in  all  but  4  of  which  the  provision  of  sick 
benefits  is  optional  with  the  local  organization. 

Of  the  1871  local  lodges  replying,  56  were  in  societies  in  which  the 
payment  of  sick  benefits  is  made  compulsory  by  the  constitution  or  laws 

merr^UrVanYh'ylVri'ior^^^^  ^^'  qualification  is  16  years  for  female 


477 

of  the  grand  lodge.  The  deduction  of  this  number  leaves  1815  replies 
which  bear  on  the  subject  of  this  section. 

Of  the  1815  local  lodges  in  societies  in  which  the  payment  of  sick 
benefits  is^  optional  with  the  local  organization,  1788  reported  their 
membership,  giving  data  which  show  a  total  membership  for  the  1788 
of  the  230,081  persons,  including  212,258  men  and  17,823  women.  Only 
525  of  the  1815  lodges,  or  28.9  per  cent,  reported  that  they  paid  sick 
benefits.  These  525  lodges,  as  nearly  as  can  be  determined  from  a 
summary  of  the  membership  statistics  reported  by  them,  have  an  aggi'e- 
gate  membership  of  approximately  63,000  persons  or  about  27  per  cent 
of  the  total  reported  membership  of  230,081.  The  number  63,000,  how- 
ever, does  not  necessarily  represent  the  number  of  members  in  the  local 
lodges  paying  sick  benefits  who  are  actually  insured  for  these  benefits, 
for  in  some  of  the  lodges  some  of  the  members  do  not  participate  in  the 
sick  benefits. 

If  the  percentage  just  mentioned  holds  true  of  the  entire  56 
fraternal  orders  which  reported  to  the  Commission  that  they  leave  the 
provision  of  sick  benefits  optional  with  the  local  lodges  about  200,000 
members  of  these  orders  are  affliliated  with  lodges  which  provide  sick 
benefits.  It  would  appear  that  about  70  per  cent  of  these  are  of  the 
wage-earning  group. 

The  amount  of  the  sick  benefit  paid  by  the  525  lodges  mentioned! 
above  ranges,  according  to  the  information  received  from  the  lodges, 
from  $2  or  $3  per  week,  to  $10  per  week  reported  by  one  lodge  which  io 
the  only  lodge  reporting  more  than  $7  per  week.  The  amount  commonly 
paid  is  $5  per  week;  but  a  considerable  number  of  lodges  pay  $4,  $6  or 
$7  per  week.  Where  the  membership  is  confined  to  women  the  benefits 
are  likely  to  be  lower  than  those  paid  where  the  membership  is  mixed  or 
restricted  to  men.  In  one  of  the  women's  orders,  for  example,  the  sick 
benefits  paid  by  the  local  lodges  reporting  range  from  $2.50  per  week  to 
$4  per  week. 

In  most  of  the  lodges  a  member  cannot  claim  sick  benefits  until  he 
has  been  a  member  for  three  months  or  more.  The  requirement  most 
frequently  reported  is  26  weeks.  Many  lodges  have  a  requirement  of  13 
weeks,  and  a  considerable  number  report  a  requirement  of  4  weeks.  One 
lodge  reports  that  it  pays  benefits  at  any  time  after  initiation ;  one  lodge 
reports  that  new  members  must  wait  52  weeks  before  claiming  benefits 
and  another,  perhaps  through  a  misunderstanding  of  the  question  con- 
cerning the  matter,  reports  that  new  members  must  wait  104  weeks  before 
claiming  benefits. 

A  considerable  number  of  the  local  lodges  require  no  waiting  period. 
The  great  majority,  however,  provide  for  a  waiting  period  of  7  or  14 
days.  Other  lodges  report  waiting  periods  which  vary  from  2  or  3  days 
to  (in  the  case  of  one  lodge)  42  days.  In  most  cases  the  benefits  when 
paid  are  counted  either  from  the  day  sickness  begins  or  is  reported  or 
from  the  beginning  of  the  second  week  of  disability. 

The  payment  of  sick  benefits  to  a  member  is  commonly  limited  to 
a  maximum  number  of  weeks  per  year,  varying  from  6  to  52,  with  13 
weeks  at  the  limit  most  frequently  fixed. 


^^^S  amount  of  the  weekly  benefit  is  commonly  reduced  to  one-half 
S  initial  amount  after  half  the  maximum  numbers  of  weeks  for  which 
the  benefit  may  be  paid  has  elapsed,  but  tliere  are  some  variations,  both 
in  the  amount  of  the  reduction  and  the  time  at  which  it  takes  effect. 

Many  of  the  lodges  failed  to  report  on  the  methods  used  in  determin- 
ing the  validity  of  claims  for  sick  benefits;  those  that  did  report  usually 
stated  either  that  the  certificate  of  a  physician  or  the  report  of  a  com- 
mittee of  tlie  lodge,  or,  sometimes,  that  both  were  required  in  support  of 

claims. 

The  benefits  are  usually  provided  according  to  the  statements  re- 
ceived from  the  local  lodges^  from  the  proceeds  of  monthly  assessments 
ranging  from  25  cents,  for  the  smaller  benefits,  to  50  cents,  the  amount 
frequently  paid  for  the  more  common  benefit  of  $5  per  week.  In  a  few 
locals  in  which  the  sick  benefit  is  $3  per  week  or  less  the  monthly  assess- 
ment is  only  10,  15  or  20  cents.  In  some  locals  in  which  the  benefits 
are  relatively  large  in  amount  or  are  payable,  if  necessary,  for  a  relatively 
long  period  the  assessments  may  run  as  high  as  75  cents  per  month  or, 
where  assessments  are  paid  annually,  the  equivalent  $9  per  year.  In 
some  lodges  additional  funds  are  sometimes  secured  from  the  proceeds 
of  dances,  picnics  or  other  entertainments. 

Of  the  525  lodges  which  reported  the  payment  of  sick  benefits,  515 
stated  that  the  benefits  covered  disability  from  accidental  injuries  as  well 
as  disability  from  sickness. 

Ninety-five,  or  about  18  per  cent,  of  the  525  lodges  reported  that 
they  employ  physicians  to  give  medical  care  to  sick  members  and  9  re- 
ported the  employment  of  nurses  for  a  similar  purpose.  No  information 
of  value  was  secured  with  respect  to  the  arrangements  made  for  the 
compensation  of  the  physicians  and  nurses  employed,  except  in  state- 
ments from  a  few  lodges  that  the  lodge  physician  received  $1  per  member 
per  year. 

(6)  Fraternal  life  insurance  societies  ivhich  provide  no  sick  or 
accident  benefits. — Nineteen  fraternal  life  insui'ance  societies  which 
operated  in  Illinois  in  1917  reported  to  the  Commission  that  they  pay 
no  sickness  or  accident  benefits  in  Illinois  through  either  the  grand 
lodge  or  the  local  lodges.  These  societies  had  an  aggregate  membership 
of  130,139  on  December  31,  1917,  of  whom  66,441,  or  51.1  per  cent, 
were  members  of  societies  for  women  only  and  the  great  majority  of  the 
remainder  members  of  the  societies  open  to  both  men  and  women.  The 
greater  difficulty  of  successfully  administering  a  plan  of  sick  benefits 
for  women  no  doubt  is  an  important  factor  in  the  explanation  of  the 
absence  of  provision  for  sick  benefits  in  the  plans  adopted  by  the  societies 
mentioned. 

(7)  Miscellaneous  benefits  provided  bij  the  fraternal  societies. — In 
addition  to  life  insurance  and  indemnities  for  specific  injuries  and  for 
loss  of  time  from  sickness  or  accidental  injuries  some  of  the  fraternal 
societies  provide  other  benefits.  Among  these  are  death  or  funeral  bene- 
fits of  relatively  small  amounts  (as  distinguished  from  life  insurance), 
old  a^e  benefits,  permanent  disability  benefits,  and  maternity  benefits. 


J 


479 

Funeral  benefits,  as  distinguished  from  life  insurance,  are  sometimes 
provided  by  the  local  lodges  of  both  the  life-insurance  and  the  non-life- 
msurance  orders.  As  reported  to  the  Commission,  they  range  in  amount 
from  the  cost  of  carriage  or  automobile  hire  and  flowers  for  the  funeral 
to  $100,  -^dth  amounts  of  $50  or  $75  perhaps  more  frequently  than  any 
other. 

In  a  few  societies  the  provision  of  funeral  benefits  is  compulsory 
upon  the  local  lodges.  In  most  of  the  societies  from  which  the  Com- 
mission secured  definite  information  on  the  matter,  the  provision  of  the 
benefits  is  optional  with  the  local  lodges. 

In  most  of  the  societies  in  which  funeral  benefits  are  optional  with 
the  local  lodges,  only  a  minority  of  the  lodges  appear  to  make  such  pro- 
vision. The  grand  secretary  of  one  women's  society  with  an  Illinois 
membership  of  about  40,000  stated  that  probably  no  more  than  6  or  8 
lodges  in  the  entire  State  paid  funeral  benefits.  Similarly  in  a  society 
with  a  mixed  membership  of  about  43,000  In  Illinois  the  grand  secretary 
repoi-ted  that  olny  a  few  lodges  paid  funeral  benefits.  In  some  societies, 
however,  a  large  proportion  of  the  lodges  make  this  provision.  A  Ger- 
man order,  with  1,200  members  in  Chicago  alone,  advises  the  Commission 
that  about  half  of  its  members  in  Chicago  carry  funeral  benefits.  Re- 
ports received  by  the  Commission  from  79  local  lodges  of  a  Polish  order 
of  mixed  membership,  wdth  216  local  lodges  in  the  State,  show  that  31 
of  the  79  provide  funeral  benefits.  Similar  reports  from  29  of  40  local 
lodges  of  a  Swedish  order  show  that  17  of  the  29  make  such  provision. 
The  total  number  of  fraternal  societies,  both  life-insurance  and  non-life- 
insurance,  known  to  the  Commission  to  have  one  or  more  local  lodges 
paying  funeral  benefits  in  Illinois  is  33. 

All  things  considered,  it  is  apparent  that  tlie  provision  of  funeral 
benefits  by  the  local  lodges  of  fraternal  societies  in  Illinois  reaches  only 
a  minority  of  the  membership  of  these  orders  in  the  State.  This  fact 
is  probably  to  be  explained  in  large  part  by  the  superior  attractiveness 
of  the  life  insurance  provided  by  the  grand  lodges  of  the  life  insurance 
orders  which  can  be  purchased,  in  some  cases,  in  amounts  as  low  as  $100 
or  $250. 

One  Scandinavian  order  reports  through  its  grand  lodge  that  al- 
though it  provides  no  funeral  benefits  for  its  members  through  either 
the  grand  lodge  or  the  local  lodges,  these  benefits  as  well  as  sick  benefits 
are  provided  through  two  auxiliary  benefit  societies  to  which  members 
of  the  fraternal  order  may  belong  if  they  choose.  These  auxiliaries  pro- 
vide death  benefits,  respectively,  of  $200  and  $100. 

In  some  of  the  societies  the  grand  lodge  pays  the  funeral  expenses  of 
a  deceased  member,  not  exceeding  a  fixed  amount,  as  $100,  upon  receipt 
of  the  death  certificate  and  undertaker's  bill  from  the  secretary  of  the 
local  lodge,  and  deducts  the  amount  so  paid  from  the  death  benefit  pay- 
able to  the  beneficiary  of  the  deceased.  This  practice  appears  to  be  de- 
signed chiefly  to  insure  re-imbur^ment  of  the  local  lodge  for  money 
advanced  for  funeral  expenses  or 'to  protect  the  local  lodge  from  loss  on 
payments  which  it  has  guaranteed  to  undertakers. 


480 


The  laws  of  Illinois  authorize  fraternal  beneficiary  societies  to  pay 
benefits  to  members  who  are  not  less  than  70  years  of  age  for  disability 
arising  from  old  age.  Twenty-five  societies  reported  that  they  make 
provision  for  the  payment  of  such  benefits.  In  some  societies  old  age 
disability  is  treated  as  any  other  kind  of  total  and  permanent  disability; 
in  others  special  provision  is  made  for  it. 

In  some  societies  old  age  disability  payments  are  made  at  the  rate  of 
10  per  cent  annually ^^  of  the  face  value  of  the  death  benefit  certificate 
held  by  the  member  until  the  value  of  the  certificate  is  exhausted  or 
reduced  to  a  specified  minimum  reserved  for  a  funeral  benefit.  In  other 
societies,  a  member  attaining  the  age  of  70  may,  if  he  chooses,  discontinue 
the  payment  of  assessments  or  premiums  and  receive  a  sum  equal  to  the 
reserve  on  his  certificate  or  some  other  specified  sum  or  a  paid-up  cer- 
tificate for  a  reduced  amount.  In  the  latter  societies  attainment  of  age 
70  seems  to  be  accepted  as  conclusive  presumption  that  a  member  is  totally 
and  permanently  disabled,  regardless  of  his  physical  condition. 

The  foregoing  description  applies  to  old  age  benefits  paid  by  certain 
societies  from  which  the  Commission  received  fairly  complete  information. 
Whether  or  not  it  also  applies  more  or  less  accurately  to  the  old  age 
benefits  paid  by  other  societies  is  not  known. 

Seventeen  societies  reported  the  provision  of  total  and  pennanent 
disability  benefits.  In  one  society  these  benefits  are  merely  specific  injury 
indemnities.  In  other  societies  the  benefits  are  paid  for  permanent  and 
total  disability  arising  either  from  sickness  or  from  accidental  injuries 
and  are  charged  against  the  amount  promised  in  the  death  benefit  cer- 
tificate. In  most  of  the  societies  members  have  the  option  of  paying 
extra  for  permanent  and  total  disability  benefits  or  of  purchasing  cer- 
tificates without  these  benefits;  in  one  or  two  societies  the  benefits  are 
features  of  all  contracts  written. 

The  amount  paid  for  permanent  and  total  disability  and  the  manner 
of  its  payment  varies  from  society  to  society.  One  society  pays  10  per 
cent  of  the  value  of  the  death  benefit  certificate  each  year  until  this  value 
is  reduced  to  $100  which  is  reserved  for  a  funeral  benefit.  Another 
society  pays  the  benefit  at  the  rate  of  $12.50  per  month  per  $1,000  of 
hfe  msurance  carried  until  the  amount  of  the  insurance  is  exhausted,  or, 
m  the  case  of  term  insurance,  until  the  term  for  which  the  certificate 
was  written  has  expired.  Another  society  pays  a  lump  sum,  varying 
from  $125  to  $500  according  to  the  rates  paid  for  the  certificate"  for 
pennanent  and  total  disability  caused  by  chronic  illness  or  permanent, 
total  paralysis. 

Nine  fraternar  societies  which  operated  in  Illinois  in  1917  reported 
to  the  Commission  that  they  make  provision  for  maternity  benefits.  One 
society  pays  $10  for  the  first  30  days  after  confinement  and  the  regular 
sick  benefit  of  $1,  $2,  or  $3  per  day,  according  to  the  rate  paid  by  the 
member,  thereafter.  Another  reports  that  it  pays  a  maternity  benefit 
(t  $10.  A  third  pays  sick  benefits  for  two  weeks  in  maternity  cases.  A 
lourth  makes  the  most  ample  provision  for  maternity  benefits  which  has 
bmib^ht  to  the  attention  of  the  Commission.     This  societv  amended 

"Sometimes  discounted  to  present   value. 


481 

its  laws  in  1917  to  enable  it  to  pay  a  maternity  benefit  of  $50.  Members 
under  40  years  of  age,  who  carry  at  least  $500  of  life  insurance  in  the 
society  and  can  furnish  a  certificate  of  good  health,  are  eligible  to  partici- 
pate in  the  benefit  plan  upon  payment  of  an  assessment  of  60  cents  per 
month. 

(8)  The  fraternal  societies  as  an  aid  in  the  solution  of  the  health 
insurance  proiem. — It  is  apparent  that  the  fraternal  societies  have  not 
found  a  complete  solution  of  the  problem  of  providing  wage-earns  with 
insurance  against  sickness  and  non-industrial  accidents.  The  loss  of  time 
benefits  which  they  provide,  although  usually  of  material  assistance,  are 
far  from  adequate  in  amount  and  are  often  inadequate  in  the  length  of 
time  for  which  they  may  be  paid.  These  defects  are  due  chiefly  to  the 
fact  that  wage-earners  in  the  fraternal  orders  cannot  or  will  not  pay  for 
adequate  benefits.  They  are  defects  which  are  common  to  all  forms  of 
personal  insurance  purchased  by  wage-earners  in  the  United  States  except 
funeral  benefits  of  small  amounts  provided  by  the  fraternal  societies  and 
industrial  life  insurance  companies  and  in  certain  other  ways.  But  even 
if  the  benefits  provided  by  the  fraternal  societies  were  adequate  to  meet 
the  needs  of  the  members  of  the  societies,  they  would  still  fall  far  short  of 
a  complete  solution  of  the  problem  of  providing  wage-earners  with  health 
insurance  unless  means  could  be  devised  of  persuading  all  wage-earners, 
not  otherwise  insured,  to  apply  for  membership  in  fraternal  societies  and 
of  assuring  their  election  to  membership.  It  can  be  said,  therefore,  and 
without  giving  offense  to  members  of  the  fraternal  societies,  for  they 
recognize  and  admit  this  fact,  that  fraternal  health  insurance  at  best  can 
only  be  an  aid  in  the  solution  of  the  problem.  But,  it  may  be  added, 
if  properly  improved,  fraternal  health  insurance  may  be  a  very  material 
aid  in  actually  solving  the  problem  as  it  has  been  in  attacking  it. 

One  of  the  greatest  needs  in  fraternal  health  insurance  at  the  present 
time  is  standardization  on  the  basis  of  the  best  practice  the  societies  have 
developed.  The  array  of  insurance  plans  now  used  by  the  fraternal 
societies  providing  insurance  against  sickness  is  bewildering  even  to  those 
expert  in  insurance.  Standardization  of  benefit  plans  would  not  only 
aid  wage-earners  in  selecting  plans  best  suited  to  their  needs  but  it  would 
also  aid  in  the  development  and  improvment  of  those  plans.  Com- 
petition among  fraternal  societies  for  members  and  competition  between 
these  organizations  and  other  carriers  would  take  place  upon  a  higher 
plane  and  would  probably  have  greater  reference  to  costs  of  management 
than  it  does  at  present. 

Standardization  of  the  kind  here  suggested  does  not  mean  deadening 
and  stagnating  uniformity  any  more  than  does  standardization  of  life  and 
fire  insurance  contracts  and  practices.  It  means  progress  along  intelli- 
gent and  intelligible  lines  in  the  genuine  improvement  of  benefit  contracts 
and  the  diminution  of  opportunities  for  the  incompetent  promoter  of 
fraternal  insurance  who  occasionally  makes  his  appearance  in  Illinois. 

Another  need  in  fraternal  health  insurance  is  a  greater  degree  of 

supervision.     This  especially  true  in  respect  to  the  sick  benefits  provided 

by  the  local  lodges.     In  some  societies  the  local  lodges  pay  benefits  and 

collect  dues  for  them  that  are  more  or  less  subject  to  the  control  of  the 

—31  HI 


482 

grand  lodge  to  whom  the  local  lodges  report  the  amount  and  number  of 
claims  paid.  But  this  supervision  is  very  loose — it  does  not,  so  far  as 
the  Commission  has  learned,  extend  in  any  society  to  the  auditing  of  the 
books  of  the  local  order  nor  to  the  examination  of  the  assets  available 
for  the  payment  of  benefits.  In  most  of  the  societies  which  authorize 
the  payment  of  sick  and  other  benefits  by  the  local  lodges  even  the  loose 
degree  of  supervision  described  above  does  not  prevail.  In  fact,  as  has 
been  pointed  out  in  an  earlier  portion  of  this  study,  the  oJ0B.cers  of  most 
of  the  grand  lodges  do  not  even  know  what  local  lodges  pay  benefits  and 
what  lodges  do  not  pay  them  except  in  those  societies  which  make  the 
payment  of  benefits  compulsory  upon  the  local  lodges. 

Finally,  in  view  of  the  great  importance  of  the  fraternal  orders  in  the 
provision  of  health  and  allied  forms  of  insurance  for  wage-earners  at  the 
present  time  and  their  probable  importance  in  the  future,  it  would  seem 
desirable  to  place  the  Superintendent  of  Insurance  in  a  position  to  exercise 
closer  supervision  over  the  activities  of  the  orders,  especially  the  activities 
of  the  local  lodges,  and  to  give  him  the  power  and  funds  necessary  to 
permit  him  to  encourage  the  further  development  of  sound  and  beneficial 
forms  of  health  insurance  in  the  fraternal  orders. 


483 


SPECIAL  REPORT  VIII.     INDUSTRIAL  LIFE  INSURANCE. 

(By  William  Duffhis.) 


I.  Introductory. 

Industrial  life  insurance  has  been  defined  as  "life  insurance  for 
small  amounts,  ichiefly  on  the  lives  of  wage-earners  and  members  of 
their  immediate  families,  with  premiums  payable  weekly  and  collected 
from  the  houses  of  the  insured."^  It  is  often  referred  to  simply  as 
"industrial  insurance."  The  adjective  "industrial"  is  used  because  this 
form  of  insurance  is  "especially  designed  to  meet  the  requirements  of  the 
wage-earning  or  industrial  population/^^  Industrial  life  insurance 
might  well  be  called  "burial  insurance" — a  name  which  is  sometimes 
applied  to  it — if  a  more  accurately  descriptive  term  were  desired,  for 
term"its  primary  purpose  is  to  provide  *  *  *  an  absolutely  certain 
method  of  acquiring  the  funds  necessary  to  assure  a  decent  burial 
and  the  payment  of  the  expenses  for  medical  attendance  during  the 
last  illness/'^ 

The  Commission  deemed  an  investigation  of  industrial  life  insur- 
ance desirable  for  the  following  reasons :  first,  this  form  of  insurance  is 
designed,  as  has  just  been  indicated,  to  provide  indemnity  for  some  of 
the  results  of  sickness  and  accidents  and  it  is  thus  closely  allied  to 
health  insurance;  second,  the  problems  of  industrial  life  insurance  and 
industrial  heath  and  accident  insurance  are  similar  at  many  points; 
third,  the  suggestion  has  been  made  that  the  industrial  life  and  the 
industrial  health  and  accident  insurance  businesses  might  be  combined 
in  the  interest  of  economy;*  and,  fourth,  it  has  been  alleged  that  the 
industrial  life  insurance  companies  "absorb  the  greater  part  of  the 
available  resources  for  insurance  purposes  in  families  of  small  income" 
and  leave  little  or  nothing  for  the  purchase  of  health  insurance.^ 

II.  Belative  Importance  of  Industrial  Life  Insurance. 

Industrial  life  insurance  business  of  the  United  States  is  a  business 
of  vast  proportions.  Exact  data  as  to  the  number  of  industrial  life 
insurance  policies  in  force  in  the  United  States  at  the  present  time  are 
not  available  but  a  recent  estimate  places  the  number  at  38,000,000® 
and  this  estimate  would  appear  to  be  fairly  accurate.     The  same  esti- 

1  John  P.  Dryden,  late  president  of  the  Prudential  Insurance  Company  of 
America.  Addresses  and  Papers  on  Life  Insurance  and  other  Subjects,  p.   85. 

2  Solomon  S.  Huebner,  Life  Insurance,  p.   275. 
»Ibid.,  p.  275. 

*  See  the  study  of  Casualty  Companies,  p.   403. 

'^  Charles  Richmond  Henderson,  Industrial  Insurance  in  the  United  States, 
1908,  p.  162.  _     ^ 

8  News  item  in  the  Spectator,  December  12,  1918.  p.  23.  Forrest  F.  Dryden, 
President  of  the  Prudential  Insurance  Company  of  America,  states  in  an  article 
published  in  June,  1918,  that  conservatively  estimated  there  were  at  the  time  he 
wrote  about  36.000.000  industrial  policies  in  force  in  the  United  States  "providing 
not  less  than  $5,000,000,000  of  insurance  protection."  North  American  Review,  Vol. 
207,  pp.   862-867,  June,   1918. 


484 


mate  places  the  number  of  ordinary  life  insurance  policies  outstanding 
against  the  old-time  companies  in  the  United  States  at  $7,800,000.  The 
industrial  policies  in  force  therefore  outnumber  the  ordinary  policies 
by  almost  five  to  one,  if  the  latter  estimate  is  correct.  When  the  amount 
of  insurance  in  force  on  the  two  types  of  contracts  is  considered,  how- 
ever, the  situation  is  reversed  because  of  the  small  amounts  carried  on 
the  industrial  contracts.  The  aggregate  amount  of  ordinary  life  insur- 
ance in  force  for  the  life  insurance  companies  of  the  United  States  on 
January  1,  1918,  was  $21,965,594,232  while  the  aggregate  amount  of 
industrial  life  insurance  in  force  on  the  same  date  was  only  $5,223,- 
415,465/ 

The  first  company  successfully  to  attempt  the  provision  of  life 
insurance  for  wage-earners  on  the  industrial  plan  in  the  United  States 
was  the  Prudential  Insurance  Company  of  America  organized  in  N'ewark, 
New  Jersey,  in  1875  as  the  Prudential  Friendly  Society.  The  Metro- 
politan Life  Insurance  Company  and  the  John  Hancock  Mutual  Life 
Insurance  Company  began  writing  industrial  policies  in  1879.^  The 
following  table  shows  the  growth  of  industrial  life  insurance  during 
the  first  forty  years  after  the  beginning  in  the  United  States  in  1875.^ 


Number 

of 

companies. 

Insurance 

written  daring 

the  year. 

Insurance  in  force  at  end  of  year. 

Year. 

Number  of 
policies. 

Amount. 

1876 

1 

3 

3 

9 

11 

18 

20 

22 

25 

24 

24 

$          727, 168 

34,768,035 

93,736,727 

242,250,959 

380,832,362 

566,037,936 

661,097,015 

749,717,264 

999,079,322 

1,013,676,330 

1,047,036,454 

$         4,816 

228,357 

1,360,376 

3,875,102 

6,943,769 

11,215,531 

16,869,758 

23,044,162 

33,370,638 

35,780,316 

38,373,272 

$           443,072 

19,590,780 

144,101,632 

428,037,245 

01 Q     KOI      K7Q 

1880 

1885 

1890 

1895 

1900 

1,468,474,534 
2,309,886,554 
3,179,489,541 
4,431,754,866 
4, 803, 856, 730 
5,193,830,295 

1905 

1910 

1915 

1916 

1917 

Little  comment  on  this  table  seems  necessary.  The  data  shown 
clearly  indicate  that  industrial  life  insurance  has  found  a  rather  rapidly 
increasing  sale  among  the  wage-earners  of  the  country  and  that  a  large 
proportion  of  wage-earning  families  now  make  use  of  it. 

It  is  evident  from  the  next  table  that  industrial  life  insurance 
plays  a  very  important  part  in  Illinois  in  aiding  wage-earners  to  make 
provision  for  meeting  the  expenses  of  the  last  illness  and  burial  and  that 
the  use  of  this  form  of  insurance  is  steadily  increasing.  It  is  impossible, 
however,  to  say  definitely  how  many  wage-earners  or  how  many  wage- 
earning  families  are  provided  with  industrial  life  insurance  for  the  reason 
that  some  policyholders  carry  two  or  even  several  policies  and  for  the 
further  reason  that  in  some  families  all  of  the  members  are  insured  while 
in  others  some  of  the  members  are  without  insurance. 


*The  spectator,  September  12,  191-8,  p.  143 

j^^     ®^®^*^l^.r^;.?°""^^"'    ^^tory    of    the    Prudential 
America,  pp.  115-116. 

•Compiled  from  the  Insurance  Year-Book  for  1916    p    273 


Insurance    Company    of 


485 

This  table  shows  the  growth  of  industrial  life  insurance  in  Illinois 
during  the  years  1913  to  1917,  inclusive.^" 


Year. 


Number 

of 
compan- 
ies. 


Insurance  written  during 
the  year. 


Number  of 
policies. 


Amount. 


Insurance  in  force  at  end  of  year. 


Number  of 
policies. 


Amount. 


Average  per 
policy. 


1912 

8 
6 
10 
11 
11 
13 

1913 

1914 

1915 

1916 

1917 

327,869 
349,279 
403,313 
447, 102 
434,756 
449, 183 


$50,726,299 
54,575,097 
55,762,246 
62,248,412 
62,795,481 
65,597,182 


1,642,649 
1,802,171 
1,951,700 
2,113,177 
2,306,458 
2,518,815 


$227,916,345 
245,080,388 
261,259,249 
279,764,403 
306,616,086 
336,825,822 


$138. 75 
135.99 
133.86 
132. 39 
132. 94 
133.72 


Attention  should  be  called  to  the  average  size  of  the  policies  in  force 
in  Illinois.  This  is  shown  in  the  last  column  of  the  table  for  December 
31st  of  each  year.  It  will  be  noted  that  the  average  ranges  from 
$132.39  to  $138.75 — a  fact  which  emphasizes  the  very  modest  service 
rendered  to  the  individual  wage-earner  by  industrial  life  insurance.  In 
this  connection,  however,  two  things  should  be  borne  in  mind :  first,  that 
the  wage-earner  may  insure  members  of  the  family  other  than  himself 
and,  second,  that  the  averages  shown  are  influenced  by  the  restrictions 
placed  upon  the  amounts  for  which  children  may  be  insured — a  matter 
discussed  later  in  this  study. 

III.  Policy-C ontracts  in.  Industrial  Life  Insurance. 

Although  industrial  life  insurance  is  similar  in  many  respects  to 
ordinary  life  insurance  it  has  certain  distinctive  characteristics  which 
should  be  noted.     These  characteristics  have  been  stated  as  follows : 

"1.  The  premiums  are  payable  weekly  whereas  in  ordinary  life  in- 
surance they  are  payable  annually,  semi-annually  or  quarterly.  This 
may  be  regarded  as  the  most  important  difference  since  the  feasibility  of 
industrial  insurance  depends  upon,  and  the  organization  of  the  company's 
agency  system  must  be  adapted  to,  this  particular  method  of  paying 
premiums.  Experience  has  demonstrated  the  necessity  of  very  frequent 
premium  collections  if  life  insurance  is  to  be  widely  disseminated  among 
the  wage-earning  class. 

"2.  The  premiums,  instead  of  being  payable  at  the  office  of  the 
company  as  is  usually  the  case  in  ordinary  life  insurance,  are  collected 
weekly  by  the  companies'  agents  from  the  homes  of  the  insured. 

"3.  The  amount  of  the  insurance  is  "adjusted  to  the  unit  of 
premium,''  customarily  five  cents,  or  a  multiple  thereof,  up  to  seventy 
cents.  Thus  in  industrial  insurance  we  speak  of  five,  ten  or  fifteen 
cent  policies,  and  the  amount  of  insurance  available  for  that  weekly 
premium  will  vary  according  to  age  of  entry  and  will  represent  odd 
figures.  In  ordinary  life  insurance,  on  the  contrary,  the  unit  is  the 
amount  of  insurance.  We  thus  refer  to  $1,000,  $2,000,  etc.,  policies, 
and  the  factor  that  varies  with  the  age  of  entry  is  the  premium. 


"  Compiled  from  the  Reports  of  the  Insurance  Superintendent  of  Illinois. 


486 


^^^^The  insurance  is  extended  to  every  member  of  the  family,  an^ 
the  companies  therefore  issue  both  adult  and  infantile  policies,  while 
in  ordinary  life  insurance  the  business  is  confined  almost  wholly  to 
adult  risks.  In  nearly  all  the  companies  industrial  insurance  is  made 
to  comprise  all  ages  between  one  and  seventy.  Some  of  the  smaller 
companies  even  insure  childm  before  they  are  one  year  old."" 

Industrial  life  insurance  is  written  on  whole  life/^  limited  payment 
life  and  endowment  policies  which  resemble  closely,  in  most  respects, 
the  policies  used  in  ordinary^  life  insurance.  The  industrial  life  policies 
differ  from  ordinary  policies,  however,  in  the  fact  that  if  the  policy- 
holder dies  within  six  months  of  the  date  of  the  contract  the  amount 
pavable  is  usually  only  one-half  of  the  amount  of  the  insurance  and  in  the 
further  fact  thai  no  cash  surrender  values  are  payable  until  the  policy 
has  been  in  effect  for  ten  years  or  so.^^  There  are  also  a  number  of 
minor  differences  which  need  not  be  noted  here. 

Industrial  life  insurance  policies,  like  ordinary  life  insurance 
policies,  may  be  written  on  either  the  participating  or  the  non-partici- 
pating plan,  that  is,  the  policyholders  may  or  may  not  be  given  the  right 
to  share  in  the  dividends  of  the  insurance  company.  Until  the  past  few 
years  most  industrial  life  policies  were  written  on  the  non-participating 
basis  but  it  had  been  the  practice  of  the  two  leading  companies  for  years 
to  distribute  "large-surplus  accumulations  to  their  policyholders  in  the 
form  of  voluntary  dividends,  which  might  otherwise  have  been  paid  to 
the  stockholders."^*  In  1915  the  Metropolitan  Life  Insurance  Company, 
of  New  York,  which  leads  all  other  companies  in  the  writing  of  in- 
dustrial life  insurance,  and  which  had  up  to  that  time  been  a  stock  com- 
pany, retired  its  capital  stock  and  became  a  mutual  company.  In  the 
same  year  the  Prudential  Insurance  Company  of  America,  which  is  the 
closest  competitor  of  the  Metropolitan  in  the  writing  of  industrial  life 
insurance,  practically  completed  its  mutualization.^^  The  company  which 
stands  third  in  the  sale  of  industrial  life  insurance  is  the  John  Hancock 
Mutual  Life  Insurance  Company.  It  and  several  of  the  smaller  com- 
panies in  tlie  industrial  field  are  mutual  companies.  It  is  therefore  safe 
to  say  that  approximately  90  per  cent  of  the  industrial  life  insurance 
policies  in  force  in  the  United  States  are  now  on  a  participating  basis. 

"Some  companies  give  the  insured,  in  case  he  is  dissatisfied  with  his 
contract,  the  privilege  of  surrendering  the  same  within  two  weeks  after 
its  issue  and  receiving  a  refund  of  the  premium.  Other  companies,  again, 
give  the  insured  the  opportunity  of  converting  his  industrial  policy  into 
one  on  the  ordinary  plan,  provided  that  when  application  for  such  con- 
version IS  made  the  insured  has  attained  a  stated  age  (usually  18  or  over), 
has  paid  all  his  premiums  for  ten  or  some  other  stipulated  number  of 
years,  and  can  offer  satisfactory  evidence  of  insurability.  In  making 
such  conversions  it  is  customary  to  give  the  full  legal  reserve  as  a  sur- 

"  Solomon  S.  Huebner.  Life  Insurance,  pp    277-278 
Of  70  o?  7?""^  °'  ^^^  so-called  whole  life  policies  the  premiums  cease  at  the  age 
"  Solomon  S.  Huebner.  TAfe  Insurance,  p    282 
"  Solomon  S.  Huebner.  Life  Insurance,  p"  282* 
"According  to  the  Insurance  Year-Book  fnr  iqir    n    oat    *-h^  *^„^+^       ^>       +v,fl. 


487 

render  value  and  to  apply  the  same  in  payment  of  premiums  on  the  ordi- 
nary policy."^^ 

Mention  should  be  made  of  two  features  of  industrial  life  insurance 
that  are  of  importance  in  the  insurance  of  children.  One  of  these  features 
is  the  limitation  of  the  amount  of  insurance  that  may  be  carried  on  the 
life  of  a  child  to  what  is  supposed  to  be  sufficient  to  pay  the  normal  ex- 
penses of  the  last  illness  and  burial;  the  other  is  the  fact  that  the  in- 
surance purchasable  for  a  given  weekly  premium  increases  with  the  age  of 
the  child  until  the  age  of  10  is  reached. 

The  amount  of  insurance  which  may  be  carried  on  the  life  of  a  child 
is  closely  limited  in  order  to  avoid  the  moral  hazard  which  might  exist 
if  children  were  insured  for  amounts  greatly  in  excess  of  the  probable  ex- 
penses of  the  last  illness  and  burial.  The  limit  set  varies  according  to  the 
age  of  the  child. 

The  fact  that  the  amount  of  the  insurance  purchasable  for  a  given 
premium  increases  with  the  age  of  the  child  until  age  10  is  reached  is 
explained  by  the  fact  that  the  mortality  of  children  normally  decreases 
from- birth  to  about  age  10,  after  which  it  increases  constantly  to  the  high- 
est age  which  is  attainable.  For  this  reason  the  policies  issued  hy  the 
industrial  life  insurance  companies  are  divided  into  two  general  classes: 
the  "infantile  policies"  applying  to  chilldren  under  10  and  the  "adult" 
policies  applying  to  all  insurable  persons  from  age  10  to  the  highest  in- 
surable age. 

IV.  Cost  of  Industrial  Life  Insurance . 

As  compared  with  the  premium  rates  for  ordinary  life  insurance 
the  premiums  charged. for  industrial  life  insurance  are  high.  Industrial 
life  insurance  is  necessarily  an  expensive  form  of  insurance.  The  reasons 
for  this  fact  have  been  set  forth  as  follows : 

"In  the  first  place,  Industrial  policyholders,  as  a  class,  are  from  the 
point  of  view  or  mortality,  worse  risks  than  Ordinary  policyholders. 
The  adults  of  the  Industrial  classes  are  engaged  in  more  hazardous  trades, 
and  often  do  not  receive  the  same  care  and  medical  attention  during 
periods  of  illness  as  do  most  Ordinary  policyholders.  The  higher 
mortality  is  clearly  observed  when  we  compare  the  number  of  deaths 
expected  from  the  American  Experience  Table  with  that  from  the 
Standard  Industrial  Table  at  corresponding  ages."^^ 

"It  will  be  seen  at  once,  from  a  comparison  of  the  figures  in  the  last 
column  of  each  of  the  tables,  that  the  mortality  of  Industrial  policy- 
holders is  much  higher  than  that  of  Ordinary  policyholders  at  the  cor- 
responding ages.  Thus,  at  age  25  there  are  953  Industrial  deaths  as 
against  807  Ordinary  deaths  for  every  100,000  living  policyholders. 
This  difference  becomes  even  more  marked  in  the  later  ages.  Thus,  at 
age  45,  although  there  are  about  10,000  fewer  living  among  the  Industrial 
risks,  there  are  nearly  300  more  deaths  among  them  in  that  one  year. 

"Solomon  S.  Huebner.  Life  Insurance,  p.  281. 

"  Lee  K.  Frankel  and  Louis  I.  Dublin,  The  Principles  of  Life  Insurance,  A 
Course  of  Instruction  for  the  Agents  of  the  Metropolitan  Life  Insurance  Cotnpany, 
Lesson  IX,  1917  edition,  p.  6. 


488 


Keduced  to  a  basis  of  100,000  living,  at  that  age,  there  are  1,735  In- 
dustrial as  against  1,116  Ordinary  deaths."^®  -j 


American  experience  mortality  table. 


Age. 


Number 
living. 


Number 
dying. 


Deaths  per 
100,000. 


Standard  industrial  mortality  table. 


Number 
living. 


Number 
dying. 


Deaths  per 
100,000. 


^ 


25 
30 
35 
40 
i5 
50 
55 
60 


89,032 

718 

807 

83,2.57 

793 

85,441 

720 

843 

79,028 

917 

81,822 

732 

895 

74,319 

%5 

78,106 

765 

979 

69,413 

.   1,017 

74, 173 

828 

1,116 

64,157 

1,113 

69,804 

962 

1,378 

58,316 

1,262 

64,563 

1,199 

1,857 

51,614 

1,469 

57,917 

1,546 

2,669 

43,782 

1,717 

953 
1,160 
1,299 
1,465 
1,735 
2,164 
2,846 
3,922 


"* 


^  *  You  will  see  that  the  number  of  Industrial  deaths  per 
100,000  policyholders  exceeds  the  number  of  Ordinary  deaths  at  the 
same  ages  all  the  way  from  about  20  to  about  50  per  cent. 

"The  cost  of  Industrial  insurance  is  still  further  increased  by  the 
expense  involved  in  collection  and  supervision.  In  Ordinary  insurance, 
the  policyholder  usually  pays  the  premiums  at  the  office  of  the  Company, 
but  in  the  Industrial  department  weekly  house  to  house  collections  are 
the  rule.  Moreover,  the  weekly  pa}anent  of  premiums  makes  necessary  a 
very  complicated  system  of  bookkeeping,  with  a  large  office  staff  to  look 
after  the  many  details  of  the  business. 

"These  factors  make  the  loading  on  Industrial  policies  much  higher 
than  is  necessary  on  the  Ordinary  plan.  Thus,  the  management  ex- 
penses of  Ordinary  life  insurance  companies  approximate  20  per  cent 
of  the  premium  receipts.  The  same  item  in  Industrial  companies,  on 
the  other  hand,  is  considerably  higher.  In  some  of  the  smaller  ones  in 
which  most  of  the  business  is  new,  the  expenses  rise  to  over  50  per  cent 
of  the  premium  receipts.  The  larger  companies,  where  conditioQS  of 
the  business  are  more  settled,  have  been  able  to  reduce  this  item  to  less 
than  40  per  cent,  and  in  the  Metropolitan,  where  the  rate  is  lowest,  it  is 
about  35  per  cent.     *     *     * 

"The  higher  cost  of  Industrial  insurance  is,  therefore,  justified  on 
these  grounds.  The  workingman  must  pay  a  higher  price  for  his  in- 
surance, as  for  everything  else  which  he  buys  in  small  quanities  and  pays 
for  in  installments.  He  pays  for  the  service  rendered  to  him,  a  service 
which  is  neither  required  by  nor  furnished  to  Ordinary  policyholders.''^^ 

The  following  table  shows  the  premiums  received  and  the  losses 
paid  with  respect  to  industrial  life  insurance  in  Illinois  for  each  year 
from  1911  to  1917  inclusive,  for  all  of  the  companies  writing  this  form 
of  insurance  within  the  State.^" 

J»/Wd.,  Lesson  II,  1916  edition,  pp.  9-10 
tlon.  p^*?^  ^'  ^''"^"^^^  ^"^  ^°"^s  I-  Dublin,  work  cited  above.  Lesson  IX,  1917  edi- 
1917*and"l91^8^  ^^^^  *^®  iZeporfs   of  the  Insurance  Superintendent  of  lUinois  for 


489 


Year. 

Premiums 
received. 

Losses  paid. 

Ratio  of  losses 

paid  to  pre- 
miums received 
— per  cent. 

1911 

$  6,692,755.77 
7,445,708.00 
8,084,626.70 
8,629,522.33 
9,445,216.31 
10,274,288.37 
11,360,001.28 

$2,009,579.01 
2,205,337.00 
1,544,337.11 
2,560,984.56 
2,777,308.12 
3,083,078.88 
3,470,266.45 

30.03 

1912 

29.74 

1913 

19.10 

1914 

29.67 

1915 

29.40 

1916 

30.01 

1917 

30.05 

For  purposes  of  comparison  with  the  ratios  of  losses  paid  to 
premiums  received  with  respect  to  industrial  life  insurance  shown  in 
the  last  column  of  the  table  the  corresponding  ratios  for  ordinary  life 
insurance  in  force  in  Illinois  during  the  same  period  are  worthy  of  note. 
These  ratios  are  as  follows:  1911,  31.78  per  cent;  1912,  30.14  per  cent; 
1913,  29.55  per  cent;  1914,  36.39  per  cent;  1915,  34.94  per  cent;  1916, 
37.65  per  cent;  1917,  31.65  per  cent. 

In  interpreting  the  significance  of  the  ratio  of  losses  paid  to 
premiums  received  in  industrial  life  insurance  in  the  years  indicated 
in  the  above  table  it  is  necessary  to  call  attention  to  the  fact  that  the 
"losses  paid"  do  not  include  all  payments  made  by  the  companies  to 
their  policyholders. As  was  stated  on  a  previous  page^^  it  had  been  the 
practice  of  the  two  leading  companies  for  years  preceding  their  mutual- 
ization  to  pay  "voluntary  dividends'^  to  their  industrial  policyholders 
and  the  dividends  so  paid  and  the  dividends  paid  since  mutualization  are 
not  included  in  the  losses  shown  in  the  table.^^ 

In  1916  the  Hon.  Eufus  M.  Potts,  then  Insurance  Superintendent 
of  Illinois,  received  a  special  report  from  the  life  insurance  companies 
doing  industrial  life  insurance  business  in  Illinois  with  respect  to  the 
relation  between  the  total  payments  made  to  the  companies  since  they 
began  business  by  all  industrial  policyholders  and  the  total  payments 
made  and  funds  credited  by  the  companies  to  these  policyholders  or 
their  beneficiaries  during  the  same  time.  Mr.  Potts  has  presented  the 
data  so  gathered  with  respect  to  the  three  largest  industrial  life  insurance 
companies  to  the  Commission  in  the  form  of  the  following  table  and 
accompanying  discussion: 

AMOUNTS  PAID  AND  CREDITED  TO  INDUSTRIAL  POLICYHOLDERS  AND 
AMOUNTS  OP  PREMIUM  RECEIPTS  AND  ACCUMULATIONS  ON  THE 
FUNDS  OF  INDUSTRIAL  POLICYHOLDERS,  FOR  THE  THREE  LARGEST 
INDUSTRIAL  LIFE  INSURANCE  COMPANIES  IN  THE  UNITED  STATES. 
FROM  THE  BEGINNING  OF  EACH  COMPANY'S  INDUSTRIAL  BUSINESS 
TO  DECEMBER  31,  1915. 

Total    premium    $1,811,843,770 

Total   interest   income,    etc 195.631,58:^ 

Total    receipts    $2,007,475,352 

Total  payments   to   policyholders $    713,477,427 

Total   funds  credited   to   policyholers 529,765,435 

Total   payments   and   credits $1,243,242,862 

Percentage  of  payments  and  credits  to  receipts 61.9 

21  Page  6. 

^  Some  of  the  policies  issued  before  mutualization  contained  an  agreement  to 
pay  cash  dividends.  The  Prudential  began  writing  such  policies  in  1897.  Frederic 
L.  Hoffman,  History  of  the  Prudential  Insurance  Company  of  America,  pp.  235-237. 


490 


X  tie  percentage  of  total  payments  and  credits  to  receipts  varied  iix 
the  different  individual  companies  whose  business  is  included  m  this 
table  from  57.9  per  cent  to  64.5  per  cent.  The  average  results  for  the 
last  ten  years'  business  of  these  companies  were  slightly  better  than  for 
the  whole  period     *     *     *     used  in  the  above  calculations. 

"This  [table]  shows  that  *  *  *  the  total  amount  paid  by 
policyholders  for  insurance  is  $2,007,475,352,  but  that  the  sum  of 
$1,243,242,862  only  was  returned  to  the  policyholders.  Consequently, 
for  each  one  hundred  dollars  that  the  policy  holder  received  from  these 
life  insurance  companies,  he  paid  $161.47."^^ 

In  the  light  of  the  data  shown  in  Mr.  Pott's  statement  and  in  the 
statement  of  Messrs.  Frankel  and  Dublin  of  the  Metropolitan  quoted  on 
a  previous  page  (page  9)  it  seems  safe  to  assume  that  from  35  to  40  per 
cent  of  the  contributions  of  policyholders  to  the  industrial  life  insurance 
companies,  including  interest  earnings  on  funds  paid  in  by  policy- 
holders, are  consumed  by  expenses  of  management. 

Because  of  the  payment  of  dividends  and  the  varying  bases  upon 
which  they  are  calculated  it  is  impossible  to  show  exactly  what  an  in- 
dustrial policyholder  will  get  in  the  future  for  a  five-cent  premium  paid 
for  a  given  policy  taken  out  at  a  given  age.  The  following  tables  taken 
from  the  "Unique  Chart  for  1917"^*  show  the  benefits  promised  by  the 
companies  indicated,  exclusive  of  dividends,  in  policies  written  for  per- 
sons of  the  agea  stated  and  sold  for  unit  premiums  of  three,  or  five 
cents  per  week. 


INFANTILE  WHOLE  LIFE. 

(One  Company.) 

Payment  of  premium  ceases  on  first  anniversary  of  date  of  issue  after  insured 
reaches  age  74.  Amount  payable  provided  death  occurs  after  policy  has  been  in 
force  for  the  following  periods.     For  a  weekly  premium  of  5  cents. 


Age  next 
birthday. 


Less 

than  6 

months. 

6 
months. 

1  year. 

2  years. 

3  years. 

4  years. 

5  years. 

6  years. 

7  years. 

8  years. 


2 
3 
4 
6 
« 
7 
8 
9 


125 

$25 

$34 

$40 

$48 

$58 

$70 

$110 

$150 

25 

34 

40 

48 

58 

70 

110 

150 

208 

25 
25 

40 

48 

48 
58 

58 
70 

70 
110 

110 
150 

150 
194 

201 

29 

58 

70 

110 

150 

187 

35 

70 

110 

150 

180 

55 

110 

150 

173 

75 

150 

167 

$214 


"  Mr.  Potts  includes,  very  properly,  interest  on  funds  contributed  by  policy- 
holders and  held  in  reserve  for  them  as  part  of  the  cost  of  the  insurance  to  the 
I)ollcyholder. 

"  The  Unique  Comparative  Chart  of  Premium  Rates,  of  the  Regular  Life  /»- 
aurance  Companies,  copyright  by  Sampson  Dawe,  Boston,  pp.  366-369. 


491 


ADULT  TABLES. 
(Condensed  to  Show  Every  Fifth  Year  Only.) 


One  company. 


Age. 


♦Whole 

life, 
3  cents. 


Endow- 
ment 
at  80, 

3  cents. 


25  year 
endow- 
ment, 
5  cents. 


Another  company. 


Age. 


Whole  Ufe. 


3  cents.** 


5  cents.** 


20  annual 
pre- 
miums, 
5  cents. 


10 
15 
20 
25 
30 
35 
40 
45 
50 
55 
60 
65 


$97.20 
81.00 
67.80 
57.60 
49.20 
41.40 
34.80 
28.80 
22.80 
18.00 
13.20 
9.60 


$69.60 
59.40 
52.20 
47.00 
41.40 
36.00 
30.60 
25.80 
21.00 
16.80 
13.20 
10.20 


$56 
53 
52 
51 
50 
47 
44 
40 


10 
15 
20 
25 
30 
35 
40 
45 
50 
55 
60 


$89 

$149 

74 

124 

62 

104 

53 

89 

46 

77 

40 

66 

33 

55 

27 

45 

21 

35 

16 

27 

11 

18 

$97 
83 
72 
65 
58 
53 
47 
41 
35 


•  Premium  ceases  on  first  anniversary  of  date  of  issue  after  insured  reaches 
age  74. 

•♦Premium  ceases  at  age  70. 

V.  Industrial  Life  Insurance,  and  the  Health  Insurance  Problem. 

In  the  introductory  remarks  of  this  study  it  was  pointed  out  that 
industrial  life  insurance  and  health  insurance  are  closely  allied  in  that 
both  forms  of  insurance  are  designed  to  provide  indemnity  for  the  re- 
sults of  sickness.  It  might  be  added  that  no  form  of  health  insurance 
can  be  considered  adequate  to  the  needs  of  wage-earners  unless  either 
it  or  some  other  form  of  insurance  provides  indemnity  to  cover  the  ex- 
penses of  the  last  illness  and  burial.  It  is  therefore  in  point  to  con- 
sider briefly  the  advantages  and  disadvantages  of  industrial  life  insur- 
ance as  it  is  being  written  to-day. 

The  more  important  advantages  which  are  claimed  for  industrial 
life  insurance  may  be  summarized  as  follows : 

1.  It  provides  absolutely  safe  insurance. 

2.  It  provides  insurance  for  every  member  of  the  family. 

3.  The  premiums  and  the  system  of  collection  are  adjusted  to  the 
needs  and  the  convenience  of  wage-earners. 

4.  It  is  voluntary  and  democratic. 

5.  It  develops  habits  of  thrift  among  wage-earners. 

6.  It  familarizes  large  numbers  of  wage-earners  with  the  nature 
of  insurance  and  some  of  them  are  thereby  induced  to  provide  them- 
selves with  other  and  more  adequate  forms  of  insurance. 

7.  About  ninety  per  cent  of  the  industrial  life  insurance  in  force  is 
now  on  the  mutual  basis  and  therefore  subject  to  the  control  of  the  policy- 
holders. • 

The  first  advantage  claim.ed — that  of  absolute  assurance  that  the 
promises  made  by  the  insurance  company  to  the  insured  will  be  carried 
out  to  the  letter — must  be  acknowledged.  This  advantage  is  of  great 
importance  when  industrial  life  insurance  is  compared  with  some  of  the 


492 

many  unscientific  insurance  plans  that  have  been  tried  among  wage? 
earners  in  the  past. 

The  fact  that  industrial  life  insurance  makes  provision  for  the 
insurance  of  all  members  of  the  family  from  infants  to  persons  of  age 
70 — except  those  who  are  considered  undesirable  risks — constitutes  one 
of  the  strongest  claims  advanced  for  a  favorable  verdict  in  behalf  of 
this  form  of  insurance.  Until  the  recent  adoption  of  the  so-called 
"Whole  Family"  plan  of  insurance  by  some  of  the  fraternal  insurance 
societies"  the  industrial  life  insurance  companies  were  the  only  legally 
recognized  and  regulated  insurance  agencies  which  provided  life  insurance 
for  the  entire  family. 

The  claim  that  the  premiums  and  the  system  of  collecting  them  are 
adjusted  to  the  needs  and  the  convenience  of  wage-earners  may  be  granted 
with   the   reservation   that  further   improvement  may   conceivably   be 

possible. 

The  argument  that  industrial  life  insurance  is  desirable  because  it  is 
voluntary  and  democratic  is  most  commonly  used  in  opposition  to  pro- 
posals for  compulsory  state  or  government  insurance  of  wage-earners. 
It  is  beyoimd  the  scope  of  the  present  study  to  pass  upon  the  merits  of 
this  argument. 

The  claim  that  industrial  life  insurance  develops  habits  of  thrift 
among  wage-earners  is  obviously  true  to  a  certain  extent  as  the  large  num- 
ber of  industrial  life  insurance  policies  in  force  in  Illinois  and  in  the 
United  States  generally^,  indicates.  It  has  not  yet  been  proven,  however, 
that  the  effects  of  these  habits  of  thrift  so  developed  are  felt  to  any  im- 
portant extent  outside  the  field  of  industrial  life  insurance  although 
allegations  are  frequently  made  by  enthusiasts  over  this  form  of  in- 
surance that  the  effects  are  widespread.  In  this  connection  the  following 
opinion  of  the  average  wage-earner's  ability  and  inclination  to  save  money 
is  worth  noting: 

"That  the  average  workman  is  little  capable  of  continued  thrift 
without  supervision  is  shown  by  the  methods  adopted  by  industrial  life 
insurance  companies  in  collecting  premiums.  Agents  are  sent  to  call 
each  week  to  collect  driblets  of  surplus  earnings.  An  obligation  assumed 
will  not  be  met  unless  the  workman  is  constantly  reminded  of  it  and 
unless  it  is  brought  to  his  attention  as  a  payment  that  must  be  met.  By 
the  method  of  collection  he  is  brought  to  realize  that  the  insurance  must 
be  paid  before  other  expenses  are  reckoned.  His  resolution  must  be 
kept  up  to  the  point  of  action  by  weekly  visits.     *     *     * 

"The  success  of  industrial  insurance  is  due  to  the  system  of  persistent 
collection,  which  compels  the  workman  to  provide  first  for  his  insurance 
out  of  his  weekly  earnings.  Where  lapses  occur,  it  is  because  the  com- 
pulsion is  not  strong  enough ;  the  appreciation  of  the  need  has  weakened 
under  the  reatization  of  the  cost."^* 

The  claim  that  the  use  of  industrial,  life  insurance  familiarizes 
large  numbers  of  wage-earners  with  the  nature  of  insurance  and  leads 
some  of  them  to  provide  themselves  with  better  forms  of  life  insurance 

"  See  Special  Report  on  Fraternal  Insurance,  pp.   457. 
"Robert  Morse  Woodbury,  Social  Insurance,  pp.  24-25. 


493 

can  be  substantiated.  The  insurance  companies  instruct  their  agents 
to  sell  ordinary  life  policies  or  the  so-called  intermediate  policies  (poli- 
cies sold  in  units  of  $500  for  premiums  based  upon  industrial  mortality 
tables  and  payable  annually,  semi-annually  or  quarterly)  whenever  the 
circumstances  of  the  insured  will  permit  him  to  purchase  insurance  of 
either  of  the  kinds  mentioned.  But  it  is  not  to  be  expected  that  any 
large  proportion  of  wage-earners  will  be  able  to  provide  themselves  with 
ordinary  or  intermediate  policies  however  much  they  may  appreciate  the 
superiority  of  these  forms  of  insurance  over  the  expensive  industrial 
insurance. 

The  argument  that  the  industrial  life  insurance  business  is  now  al- 
most altogether  in  the  hands  of  mutual  companies  and  that  the  conduct 
of  the  business  is  therefore  subject  to  the  control  of  the  policyholders 
will  make  a  strong  appeal  to  many  persons  who  are  enthusiastic  over 
the  possibilities  of  voluntary  cooperation  as  a  solution  of  the  economic 
problems  of  the  day.  The  fact  that  the  mutualization  of  the  leading 
companies  practically  eliminates  the  payment  of  profits  in  the  form  of 
stock  dividends  to  private  individuals  will  meet  with  the  approval  of 
other  persons  who  object  to  the  business  of  providing  funds  for  the 
decent  burial  of  wage-earners  becoming  a  source  of  private  profit.  It 
will  be  well,  however,  not  to  expect  much  in  the  way  of  democratic  con- 
trol of  the  great  industrial  life  insurance  companies.  With  from  thirteen 
to  sixteen  million  or  even  more  policyholders  each,  they  cannot  be  con- 
trolled democratically  by  their  policyholders.  It  is  to  be  expected  that 
the  self-perpetuating  bodies  of  officers  and  directors  in  control  of  the 
largest  companies  will  continue  indefinitely  in  control  and  doubtless 
it  is  to  the  interests  of  the  policyholders  that  this  should  be  so. 

The  principal  disadvantage  of  industrial  life  insurance  is  its  high 
cost.  Another  disadvantage  is  that  the  lapses  are  many  in  spite  of 
a  system  of  remuneration  under  which  the  agents  are  as  much  interested 
in  preventing  lapses  as  they  are  in  writing  new  policies.  Though  com- 
paratively few  surrender  their  policies  after  they  have  been  carried  for  a 
few  years,  except  in  exchange  for  ordinary  policies,  many  of  the  newer 
policies  are  permitted  to  lapse  by  failure  to  keep  up  the  weekly  premiums. 
The  following  table  makes  possible  certain  comparisons  for  the  13  com- 
panies writing  industrial  life  insurance  in  Illinois  in  1917.^^ 


Number. 


Amount. 


Policies  in  effect  at  beginning  of  year 

Policies  issued,  restored  and  increased  during  year . 
Policies  terminated  during  year 

(a)  Policies  terminated  by  death 

(b)  Policies  terminated  by  maturity  and  disability 

(c)  Policies  terminated  by  expiry 

(d)  Policies  terminated  by  surrender 

(e)  Policies  terminated  by  lapse  and  decrease 

Policies  in  force  at  end  of  vear 


$32,613,257 

5,898,596 

3, 522, 051 

412,990 

11,221 

73,773 

185,988 

2,838,079 

34,989,802 


$4,412,061,643 

879,944,368 

524, 476,  .504 

53,148,924 

1,110,480 

12,716,329 

29,185,561 

428,315,210 

4,767,529,507 


Thus,  as  against  5,898,596  policies  issued,  restored  and  increased 
by  these  companies  in  1917,  2,838,079  were  terminated  by  lapse  or 
decrease.     The  number  lapsed  or  decreased  was  48.1  per  cent  of  the 

"Compiled  from  Tables  8  and  9  of  Illinois  Insurance  Report,  1918. 


number  issued,  restored  and  increased,  7.5  per  cent  of  the  total  of  those 
in  force  at  the  beginning  of  the  year  and  of  those  added  less  the  number 
terminated  otherwise  than  by  lapse  or  decrease,  and  more  than  four 
times  as  large  as  the  terminations  by  death,  maturity  and  disability,  by 
expiry,  and  by  surrender.  What  proportion  of  those  issued  are  carried 
until  death  or  maturity  or  are  surrendered  in  exchange  for  other  policies, 
and  what  proportion  lapse  we  are  unable  to  state. 

In  addition  to  the  defects  of  high  cost  and  numerous  lapses,  in- 
dustrial life  insurance  falls  somewhat  short  of  the  ideal  in  the  matter  of 
inclusiveness  because  of  the  considerable  proportion  of  members  of  the 
wage-earning  class  who  are  excluded  from  its  benefits.  The  following 
extracts  from  instructions  issued  by  a  leading  company  to  its  agents  with 
respect  to  the  selection  of  applicants  for  insurance  will  serve  both  to 
describe  and  to  explain  the  situation: 

"The  subject  of  hazard  or  risk  in  life  insurance  is  one  which  should 
be  of  great  interest  to  the  agent.  Thousands  of  applicants  are  rejected 
each  year,  and  many  more  are  not  granted  the  form  of  insurance  for 
which  they  applied.     *     *     * 

"The  favorable  selection  of  applicants  and  the  lower  mortality  which 
results  from  it,  make  it  possible  for  the  Company  to  decrease  perceptibly 
the  cost  of  insurance.  If,  on  the  other  hand,  the  officers  of  the  Company 
and  its  agents  were  to  let  up  in  their  vigilance  in  the  least,  large  numbers 
of  undesirable  persons  would  enter  and  soon  bring  about  a  higher 
rate  of  mortality,  which  would  necessarily  increase  the  cost  of  insur- 
ance.    *     *     * 

"What,  then,  are  the  factors  that  determine  an  average  or  standard 
risk?     They  are  as  follows: 

1.  Physical  condition. 

2.  Moral  condition. 

3.  Family  history. 

4.  Personal  history. 

5.  Occupation. 

6.  Insurable  interest.     *     *     * 

"The  physical  condition  of  the  applicant  is  covered  by  the  medical 
examination.  The  Company  will,  in  no  case,  insure  on  standard  plans 
any  one  who  is  suffering  from  any  organic  trouble  such  as  lung  or 
heart  disease,  from  any  disease  of  the  kidneys  or  other  ailment  which 
tends  to  shorten  life.  *  *  *  The  agent  *  *  *  should,  in  no 
case,  write  applications  for  persons  who  are  blind,  crippled  or  dis- 
eased.    *     *     * 

"Almost  as  important  as  the  physical  condition  is  the  moral  con- 
dition of  the  applicant.  This  includes  the  habits  of  the  insured.  It  is 
needless  to  say  that  those  who  associate  with  wild  company  and  indulge 
in  loose  living  usually  break  ^o\\u  at  an  early  age  and  give  the  highest 
mortality,  even  though  their  physical  condition  may  be  good  at  the  time 
of  their  application.  *  *  *  In  those  cases  where  there  is  the  slightest 
suspicion  as  to  the  moral  hazard;  the  applicants  are  investigated  by 
special  inspectors,  who  report  on  the  habits  and  general  environment  of 
the  prospect.     This  has  been  found  to  be  an  extremely  effective  method 


495 

in  eliminating  undesirable  applicants.  Some  companies  obtain  such 
reports  for  all  Ordinary  applicants.     *     *     * 

"Under  the  head  of  moral  hazard,  we  mav  also  consider  the  so-called 
lapse  hazard.  It  is  obvious  that  the  purpose  of  the  life  insurance  idea 
is  not  served  unless  the  business  written  is  of  the  kind  that  remains  in 
force.  Persons  of  a  roving  disposition  shiftless  or  unsteady  habits  or 
purposeless  lives,  are,  therefore,  to  he  avoided  as  possible  prospects.  It 
is  often  easy  to  induce  such  persons  to  sign  an  application  and  to  pay 
an  initial  premium,  but  as  they  have  no  real  faith  in  insurance  and  no 
real  desire  to  maintain  it,  they  lapse  their  policies  when  a  renewal 
premium  is  due.  The  loss  sustained  by  the  Company  and  the  agent  in 
such  a  lapse  is  more  than  financial,  for  only  too  often  does  a  person  who 
has  lapsed  a  policy,  no  matter  what  the  reason  may  be,  fancy  that  he 
has  a  grievance  against  the  Company,  which  in  the  airing  tends  to  breed 
distrust  among  those  who  are  being  canvassed,  and  discontent  among 
those  already  insured.     *     *     * 

"Together  with  the  family  histor}^  habits  and  present  physical  con- 
dition of  the  applicant  must  be  considered  his  personal  or  previous 
medical  history.  *  *  *  Yoy  instance,  those  who  have  had  repeated 
attacks  of  articular  rheumatism  in  the  last  few  years  are  no  longer 
standard  risks.  Neither  are  those  who  have  kidney  or  gall  stone  colic. 
A  man  of  light  build  with  doubtful  family  history,  whose  work  is  in- 
doors and  who  has  been  laid  up  with  bronchitis,  pneumonia,  or  pleurisy, 
is  nowhere  near  as  good  a  risk  as  one  with  a  worse  family  history  who 
is  of  robust  physique,  works  out  of  doors  and  has  never  been  ill.     *     *     * 

"It  must  not  be  supposed  that  those  who  fall  below  the  standard  in 
any  one  of  the  first  five  of  the  above  six  considerations  are  necessarily 
rejected.  In  the  earlier  days  of  life  insurance,  when  the  companies  were 
small,  thy  could  not  assume  risks  in  which  there  was  even  the  slightest 
amount  of  extra  hazard.  To-day,  on  the  other  hand,  many  companies, 
because  of  the  large  number  of  their  policyholders,  can  well  afford  to  be 
liberal  in  their  attitude  in  this  regard.  Accordingly,  only  a  small  per- 
centage  of  applications  [accepted  by  agents?]  is  rejected  outright.  In 
most  cases  where  there  is  any  question  as  to  the  safety  of  the  risk,  a 
higher  priced  or  shorter  term  policy  may  be  offered." 

The  above  instructions  are  quoted  in  no  spirit  of  adverse  criticism 
of  the  company  which  issued  them.  All  successful  life  insurance  com- 
panies follow  the  policy  set  forth  in  the  instructions  and  much  is  to  be 
said  in  favor  of  their  continuing  to  do  as  long  as  life  insurance  continues 
to  be  provided  on  a  voluntary,  individualistic  basis  where  each  person 
insured  is  supposed  to  pay  for  his  own  risk  Nevertheless,  in  the  con- 
sideration of  the  problem  of  insurance  for  wage-earners  the  fact  that 
there  are  a  considerable  number  of  persons  in  this  class  who^  because 
of  an  impaired  physical  condition,  either  cannot  obtain  insurance  at 
all  or  can  obtain  it  only  at  an  increased  cost  which  may  put  it  beyond 
their  means,  is  a  fact  which  cannot  be  ignored.  It  might  be  said,  in- 
deed, that  the  need  of  the  "impaired  risks"  for  insurance  is  more  urgent 
than  that  of  the  good  risks. 


496 

The  high  cost  of  industrial  life  insurance  is  inherent  in  the  system 
of  individual  solicitation  and  weekly,  house  to  house  collection  of 
premiums  which  characterizes  this  form  of  insurance.  There  is  no  evi- 
dence available  to 'the  Commission  to  show  that  the  high  cost  is  due  in 
any  appreciable  degree  to  wasteful  management  or  exorbitant  commis- 
sions paid  to  agents  In  fact  such  evidence  as  is  available  is  to  the  con- 
trary effect. 

It  has  been  suggested  that  the  cost  of  industrial  life  insurance  might 
be  reduced  by  providing  for  the  payment  of  premiums  monthly  instead 
of  weekly.  Men  experienced  in  the  business  scoff  at  the  suggestion. 
The  following  statement  was  written  twenty  years  ago  but  it  is  no  doubt 
as  true  to-day  as  it  was  when  it  was  written : 

"Weekly  payments  of  premiums,  instead  of  quarterly  or  even 
monthly  installments  of  annual  premiums,  are  a  necessity.  We  may 
grieve  that  it  is  so;  no  part  of  the  business  so  greatiy  increases  the  ex- 
pense; but  it  is  so,  and  the  part  of  wisdom  is  therefore  to  meet  the 
necessities  of  the  situation,  and  not  to  worry  over  them.  The  history  of 
life  insurance  is  full  of  the  failure  of  monthly  installment  plans.  No 
one  of  them  has  ever  succeeded,  despite  earnest  and  enthusiastic  effort. 
*  *  *.  There  is  no  teacher  like  experience.  There  is  no  need  even  to 
reason  about  it.  We  know  that  weekly  premiums  are  a  success ;  we  know 
that  monthly  installments  of  annual  premiums  are  a  failure.  *  *  *. 
When  you  call  for  a  monthly  premium  you  won't  get  it — it  is  either  too 
large  or  too  small.  The  industrial  policyholders  will  pay  weekly,  but  not 
monthly;  the  more  well-to-do  will  pay  quarterly  but  not  monthly."^^ 

»« Haley  Fiske,   Vice   President   of  the  Metropolitan   Life   Insurance    Company, 
Industrial  Insurance,  in  the  Charities  Review,  March,  1898. 


497 


SPECIAL  REPORT  IX.     GROUP  LIFE  AND  GROUP 
DISABILITY  INSURANCE. 

(By  William  Duffus.) 


I.  Introductory. 

Group  insurance,  as  it  is  written  to-day,  is  essentially  a  plan  for 
selling  insurance  at  wholesale  rates  to  employers  to  cover  the  lives  or 
persons  of  employees.  Usually,  although  not  always,  group  insurance 
is  issued  on  a  single  or  "blanket^ ^  policy  which  covers  the  entire  group 
of  employees,  and  provides  or  assumes  provision  for  the  collection  of 
premiums  from  the  employer  and  the  distribution  of  indemnities  by 
him  to  beneficiaries.  Sometimes,  however,  group  insurance  is  written  in 
the  form  of  an  individual  policy  for  each  individual  in  the  group  and 
sometimes  the  indemnities  promised  are  payable  by  the  insurance  com- 
panies directly  to  beneficiaries  without  passing  through  the  hands  of  the 
employer.^  As  a  rule  the  employer  pays  the  entire  premium — one  insur- 
ance company  which  is  a  leader  in  the  sale  of  group  life  insurance  adver- 
tises its  group  insurance  as  being  for  sale  only  on  these  terms — but 
employees  sometimes  pay  part  of  the  premium  and  there  are  a  few  cases 
on  record  where  benefit  associations  of  employees  are  paying  the  entire 
premium.^  The  group  plan  is  used  chiefly  in  life  insurance  but  it  is 
also  used  by  a  few  companies  in  the  health  and  accident  insurance  busi- 
ness and  its  adoption  is  being  considered  by  others.  The  Commission 
deemed  an  investigation  of  group  insurance  desirable  for  two  reasons: 
first,  group  life  insurance  provides  indemnities  'for  wage-earners  which 
may  be  used  to  cover  the  ordinary  expenses  of  the  last  illness  and  burial 
in  addition  to  the  cost  of  temporary  maintenance  of  dependents;  and, 
secondly,  group  health  and  accident  insurance,  if  its  development  con- 
tinues, may  constitute  an  important  partial  solution  of  the  health  insur- 
ance problem  of  the  wage-earner. 

II.  Group  Life  Insurance. 

(1)  History. — At  present,  in  so  far  as  volume  of  business  is  con- 
cerned, group  life  insurance,  as  suggested  above,  is  much  the  more 
important  form  of  group  insurance.  In  fact  the  term  "group  insurance'' 
is  frequently  used  without  modification  or  explanation  to  refer  solely 
to  group  life  insurance. 

*  Edward  B.  Morris,  Actuary  Life  Department,  Travelers  Insurance  Company, 
states  that  "one  company  in  particular  has  made  a  specialty  of  writing  group 
insurance  on  the  basis  of  individual  contracts."  Proceedings  Casualty  Actuarial 
and  Statistical  Society  of  America,  1916-1917,  Vol.   3,  p.   151. 

2  Attempts  have  been  made  to  apply  the  group  plan  to  the  insurance  of  groups 
not  composed  of  the  employees  of  a  single  employer,  as,  for  example,  the  members 
of  a  local  lodge  of  a  fraternal  order,  but  insurance  of  such  groups  is  impossible 
under  the  statutory  definitions  of  grou  3  life  insurance  adopted  in  certain  stages 
and  the  definition  approved  by  the  National  Convention  of  Insurance  Commissioners 
(see  Note  1,  p.  9). 

—32  H  I 


498 

"Group  life  insurance  is  the  result  primarily  of  a  demand  from  large 
employers  of  labor,  aided  in  its  development  by  representatives  of  insur- 
ance companies,  for  a  form  of  life  insurance  adapted  to  the  needs  of 
their  employees  and  available  for  them  in  quantity  lots  at  quantity 
prices.  These  employers  have  felt  that  the  "ordinary"  and  "industrial" 
forms  of  life  insurance  sold  on  individual  policies  were  either  beyond 
the  economic  reach  of  their  employees  or,  if  within  their  means,  that 
they  were  inadequate  to  their  needs.  Plans  for  the  insurance  of  em- 
ployees are  by  no  means  new  among  employers." 

"The  files  of  most  insurance  companies  will  prove  that  a  great  deal 
of  time  has  been  spent  on  problems  that  pertain  to  this  subject — time 
very  poorly  spent  if  the  premium  return  were  considered.  Such  insur- 
ances originally  involved  the  issuance  of  individual  contracts  with  med- 
ical examination.  The  cost  invariably  proved  to  be  greater  than  the 
employer  cared  to  stand  and  most  of  such  propositions  remained  in  the 
correspondence  files  of  the  companies."^ 

Two  motives  appear  to  have  been  responsible  for  the  action  taken 
by  employers  who  have  made  use  of  group  insurance  in  their  establish- 
ments. The  first  is  a  humanitarian  motive — a  genuine,  largely  dis- 
interested desire  to  be  helpful  to  employees  in  their  efforts  to  attain 
greater  economic  security  for  themselves  and  their  dependents.  It  is 
impossible  of  course  to  measure  the  force  of  this  motive  or  the  extent 
to  which  it  has  operated  but  there  can  be  no  question  that  it  has  been 
of  very  great  importance  in  the  minds  of  those  employers  who  have 
come  to  regard  themselves  as  being,  in  a  broad  sense,  trustees  for  the 
public.  The  second  motive  is  economic — a  desire  to  improve  the  rela- 
tions existing  between  the  employer  and  his  employees  in  order  to  pro- 
mote the  greater  prosperity  of  the  business.  Employers  who  advocate 
group  life  insurance  for  the  sake  of  its  economic  advantages  to  them- 
selves lay  greater  stress  on  the  effect  which  they  believe  it  has  in  reduc- 
ing the  labor  turnover  and  in  developing  a  greater  interest  among 
employees  in  the  welfare  of  the  business  establishment  in  which  they 
are  employed.  The  advantages  claimed  for  group  insurance  are  discussed 
in  detail  in  another  portion  of  this  chapter. 

The  first  use  of  the  group  plan  in  life  insurance  is  said  to  have  been 
made  when  a  group  policy  was  written  by  "the  first  chartered  American 
life  insurance  company  on  seven  hundred  coolies  during  their  transpor- 
tation from  China  to  Panama.*  This  initial  application  of  the  plan 
appears  to  have  had  little,  if  any,  influence  in  the  subsequent  history 
of  life  insurance.  The  group  life  insurance  of  to-day  seems  to  be 
largely,  if  not  entirely,  a  development  of  the  past  decade.  The  Travelers 
Insurance  Company  of  Hartford,  Connecticut,  has  been  credited  with 
the  preparation  "in  the  fall  of  1910  (of)  a  group  contract  of  the  One 
Year  Renewable  Term  plan  in  blanket  form  *  *  *  involving  prac- 
tically all  the  principal  features  of  the  present-day  contract"  but  a  group 

»  Edward  B.  Morris,  Actuary  Life  Department,  Travelers  Insurance  Company, 
"Group  Life  Insurance  and  its  Possible  Developments,"  Proceedings  Casualty 
Actuarial  and  Statistical  Society  of  America,  1916-1917,  Vol.   3,  pp.   149-150. 

*  Ralph  H.  Blanchard  in  chapter  on  "Group  Insurance"  in  Huebner's  Life  In- 
surance, p.  304.  Hon.  Burton  Mansfield,  Insurance  Commissioner  of  Connecticut, 
states  that  "two  or  three  so-called  group  policies  were  issued  many  years  ago 
covering  the  lives  of  coolies  in  order  to  indemnify  sjiippers  transporting  these 
coolies  over  the  high  seas."  Proceedings  National  Convention  Insuurance  Commis- 
sioners, 1912,  p.  235. 


499 

insurance  contract  which  the  Equitable  Life  Assurance  Society  of  New 
York  City  wrote  for  Montgomery  Ward  and  Company  of  Chicago  in 
July,  1912,  is  "generally  known  as  the  first  important  contract  of  this 
kind  actually  issued.^ 

The  group  insurance  plan,  as  it  is  usually  applied  to  life  insurance, 
reduces  the  cost  of  insurance  by  eliminating  the  soliciting  and  the  med- 
ical examination  of  individual  "risks'^  and  by  providing  for  the  collec- 
tion of  premiums  in  lump  sums  from  employers  instead  of  separately 
from  individual  wage-earners.^  The  details  of  the  plan  will  be  explained 
in  subsequent  sections  of  this  chapter;  at  this  point  it  is  sufficient  to 
state  that  the  comparatively  low  cost  of  group  life  insurance  is  largely 
responsible  for  its  increasing  use. 

For  a  number  of  years  after  1912  the  growth  of  the  group  life 
insurance  business  was  slow.  Only  a  few  insurance  companies  were 
''pushing'^  the  group  plan;  other  companies  were  doubtful  of  its  practi- 
cability or  of  its  desirability  as  an  addition  to  other  plans  of  insurance 
in  which  they  were  interested.  Many  employers  were  (and  still  are) 
sceptical  of  the  merits  claimed  for  the  plan  as  a  specific  for  "industrial 
unrest"  and  kindred  ills;  several  State  superintendents  or  commissioners 
of  insurance  refused  to  permit  the  sale  of  group  insurance  within  the 
states  over  which  they  had  jurisdiction  or  postponed  action  on  petitions 
for  the  approval  of  group  policy  forms, '^  and  the  laws  of  a  number  of  states 
forbade  the  insurance  of  "any  life  without  a  medical  examination'^  or 
placed  other  obstacles  in  the  way  of  the  promoters  of  the  plan.  The 
insurance  companies  which  were  interested  in  the  possibilities  of  group 
insurance  continued,  however,  to  urge  its  adoption  by  large  employers 
and  the  efforts  of  the  insurance  companies  were  re-enforced  by  the  efforts 
of  original  adherents  or  converts  to  the  plan  among  employers  who 
preached  its  merits  to  fellow  employers. 

The  growth  of  group  life  insurance  in  the  United  States  during  the 
first  five  years  of  its  history  has  been  summarized  as  follows  by  Mr. 
H.  Pierson  Hammond,  actuary  of  the  Connecticut  Insurance  Depart- 
ment, in  an  address  delivered  before  the  National  Convention  of  Insur- 
ance Commissioners,  August  28,  1917 : 

"By  far  the  greater  proportion  of  group  insurance  in  the  United 
States  has  been  written  by  less  than  ten  insurance  companies.  These 
companies  are  financially  strong  and  efficiently  managed     *     *     *. 

"As  will  be  seen  in  the  following  table,  group  insurance  starting  in 
1912,  without  any  appreciable  momentum  derived  from  previous  expe- 
rience, has  developed  until  on  June  30,  1917,  there  were  approximately 
325,000  employees  in  this  country  insured  under  this  plan  for  over 
$250,000,000  in  the  aggregate,  an  average  of  over  $760  per  employee 
insured.  If  we  assume  that  an  average  family  consists  of  five  persons, 
or  possibly  four,  it  is  safe  to  say  that  probably  one  million  five  hundred 
thousand  individuals  are  directly  interested  in  this  form  of  insurance. 

"  Edward  B.  Morris,  paper  cited  above,  pp.   150-151. 

*  See  pp.  507  below  for  a  statement  of  modifications  of  these  details  in  some 
policies. 

''Proceedings  National  Convention  Insurance  Commissioners,  1912,  p.  72;  1917, 
pp.  125  and  221. 


500 


In  force. 


Number  of 
employees. 


Amount  of 
insurance. 


Dec.  31, 1912 
Dec.  31,  1913 
Dec.  31, 1914 
Dec.  31,  1915 
Dec.  31,  1916 
June  30, 1917 


11,450 

30, 125 

56,625 

105,000 

202,000 

325,000 


$  13,083,000 

28,235,000 

50, 605, 000 

83,920,000 

155,300,000 

250,000,000 


"These  figures  indicate  that  the  volume  of  group  insurance  has 
steadily  increased  since  1912.  If  you  will  compare  the  business  in  force 
at  the  end  of  1916,  with  the  corresponding  figures  as  of  June  30,  1917, 
you  will  see  that  a  large  volume  of  insurance  is  being  written  this  year 
(1917)^'« 

In  order  to  get  as  complete,  as  recent  and  as  authentic  information 
as  possible  regarding  the  nature  and  growth  of  group  life  insurance 
in  the  United  States  and  in  Illinois  the  Commission  addressed  a  ques- 
tionnaire to  all  life  insurance  companies  in  the  United  States  known 
or  thought  to  be  writing  group  insurance.  The  following  companies 
furnished  the  information  requested:  Aetna  Life  Insurance  Company, 
of  Hartford,  Connecticut;  Equitable  Life  Assurance  Society  of  the 
United  States,  of  New  York;  Guardian  Life  Insurance  Company  of 
America,  of  New  York;  Metropolitan  Life  Insurance  Company,  of  New 
York;  Prudential  Insurance  Company  of  America,  of  Newark,  New 
Jersey ;  and  the  Travelers  Insurance  Company,  of  Hartford,  Connecticut. 
One  company,  the  Guardian  Life  Insurance  Company  of  America,  re- 
ported that  it  had  discontinued  writing  group  insurance;  the  five  other 
companies  enumerated  were  all  engaged  in  the  business  at  the  time 
they  made  their  reports  to  the  Commission.  The  Commission  has  been 
unable  to  learn  how  many  companies  other  than  those  named  above 
have  written  or  are  now  writing  group  life  insurance  but  it  feels  safe 
in  saying  that  by  far  the  greater  part  of  the  group  life  insurance  which 
has  been  written  in  the  United  States  has  been  sold  on  policies  issued 
by  the  companies  named. 

The  six  life  insurance  companies  which  provided  the  Commission 
with  information  regarding  their  group  life  insurance  business  reported 
the  year  of  entering  upon  the  business  as  follows :  one  company,  1911  ;^ 
one  company,  1912;  two  companies,  1913;  and  two  companies,  1916. 
The  same  companies  reported  the  year  in  which  their  first  group  life 
policy  was  written  in  Illinois  as  follows :  one  company,  1912 ;  one  com- 
pany, 1914 ;  two  companies,  1915 ;  one  company,  1916 ;  and  one  company, 
1918.  Three  of  the  six  companies  reported  that  they  write  group  health 
and  accident  insurance  as  well  as  group  life  insurance. 

The  total  number  of  groups  covered  on  December  31,  1917  by  insur- 
ance issued  by  the  six  companies  was  1,148,  including  about  336,000 
employees  insured  for  an  aggregate  of  about  $255,000,000.^°  A  com- 
parison of  these  figures  with  data  shown  in  the  table  above  will  indicate 
the  relative  importance  of  the  six  companies  in  the  group  life  insurance 
business  of  the  United  States. 

*The  Economic  World,  July  13.  1918,  p.  57. 

•Compare  with  statement  quoted  from  Edward  B.  Morris,  p.   3.  above. 

"Although  not  absolutely  accurate  these  figures  are  approximately  correct. 


501 


(2)  Group  life  insurance  in  Illinois. — Five  of  the  six  companies 
mentioned  above  reported  group  life  insurance  policies  outstanding 
against  them  in  Illinois  on  December  31,  1917."  The  following  table 
summarizes  data  presented  to  the  Commission  by  these  five  companies: 

GROUP  LIFE  INSURANCE  WRITTEN  FOR  EMPLOYERS  IN  ILLINOIS, 

1913-1917.* 


Year  ending  Dec.  31. 

Number 
of  groups 
insured. 

Number  of 

employees 

covered. 

Amount  of 
insurance. 

Total  of 
premiums 
collected. 

1913 

2 

t31 
t66 

333 

442 

707 

3,129 

24,877 

$     277,500 

683,634 

1,011,352 

2,809,676 

20,092,851 

%  72,366.15 
63.953.42 

1914 

1915 

59. 372. 96 

1916 

83,604.62 
159,757.45 

1917 

*  The  data  shown  in  columns  2,  3  and  4  represent  the  policies  in  force  on 
December  31  of  the  years  indicated.  These  data  are  only  approximately  correct 
because  of  differences  in  the  methods  of  compilation  used  by  different  companies. 

t  Two  of  these  groups  include  employees  of  an  industrial  life  insurance  com- 
pany which  insures  its  own  employees. 

The  most  striking  feature  of  the  above  table  is  the  very  rapid 
increase  indicated  in  the  use  of  group  insurance  in  Illinois  since  1915. 
Comparisons  of  the  two  tables  above  shows  that  the  increase  has  been 
much  greater  in  Illinois  than  in  the  United  States  as  a  whole.  However 
it  should  be  noted  that  on  December  31,  1917,  only  24,877  of  the  wage- 
earners  of  Illinois  were  covered  by  the  group  insurance  shown  in  the 
table. 

The  average  amount  of  insurance  per  employee  insured  on  December 
31,  1917,  was  about  $808.  The  average  premium  collected  per  employee 
cannot  be  calculated  from  the  data  presented  in  the  table  because  of  the 
fact  that  these  data  do  not  show  the  varying  numbers  of  employees 
covered  during  the  year,  but  it  is  evident  from  the  table,  as  will  be 
shown  more  definitely  later,^^  that  the  pl-emium  per  employee  is  com- 
paratively small.  The  average  number  of  employees  per  group,  it  will 
be  noted,  increased  greatly  from  1916  to  1917;  to  be  exact,  the  increase 
was  from  101  members  per  group  on  December  31,  1916,  to  377  mem- 
bers per  group  in  1917. 

The  reports  from  the  five  companies  covered  by  the  table  show  that 
all  of  the  group  life  insurance  contracts  written  by  them  in  Illinois  in 
1917  involve  the  payment  of  the  entire  premium  by  the  employer.  De- 
tailed statements  received  by  the  Commission  from  24  employers  in 
Illinois  who  have  adopted  the  group  life  insurance  plan  show  that  in 
each  case  the  employer  pays  the  entire  premium.  It  is  therefore  safe 
to  assume  that  there  are  few,  if  any,  establishments  in  Illinois  where 
employees  contribute  money  to  the  payment  of  premiums  on  group  life 
insurance.  The  reasons  for  the  assumption  of  the  entire  premium  burden 
by  employers  (in  so  far  as  the  making  of  money  payments  is  concerned) 
appear  to  include  the  following:  first,  the  cost  per  employee  of  the 
insurance  is  comparatively  small,  averaging  probably  not  more  than 

"The  sixth  company  began  writing  group  life  insurance  in  Illinois  in  1918. 
'^  See  pp.  510  below. 


502 


$1  per  month  in  most  establishments  and  in  many  considerably  les™ 
second,  the  division  of  the  premium  between  employer  and  employee 
involves  difficulty  in  making  the  plan  universal  in  an  establishment, 
whether  participation  in  the  plan  is  made  optional  or  compulsory  on 
the  part  of  the  employee;  third,  group  insurance  is  probably  more 
effective  as  a  means  of  getting  the  good-will  of  employees  if  the  pre- 
mium is  paid  entirely  by  the  employer  than  it  is  if  the  employees  are 
compelled  to  pay  part  of  the  premium;  and  fourth,  the  advocates  of 
group  insurance  contend  that  it  ''pays  for  itself  by  the  increased  loyalty 
and  efficiency  of  employees  which  is  alleged  to  follow  the  adoption  of 
the  plan. 

(3)  The  group  life  insurance  policy. — Usually,  as  has  already  been 
stated,  group  life  insurance  is  issued  on  a  "blanket"  policy  which  covers 
the  lives  of  all  members  in  the  group.^^  The  most  common  type  of  group 
life  contract  is  the  one-year  renewable  term  contract.  Occasionally  group 
life  insurance  is  written  on  other  types  of  contract,  such  as  the  five  or 
ten-year  term,  the  endowment  or  the  whole-life  plan.  /fOt  the  24  em- 
ployers in  Illinois  who  furnished  the  Commission  with  detailed  infor- 
mation concerning  group  life  insurance  plans  which  they  have  adopted, 
four  stated  that  the  policies  which  they  hold  are  "whole-life"  policies  but 
it  is  possible  that  in  some  cases  this  statement  was  made  through  a  mis- 
apprehension as  to  the  distinction  between  whole-life  policies  and  renew- 
able term  policies  which  may  be  continued  from  year  to  year  during  the 
greater  part  of  a  life  time.  The  general  preference  given  the  one-year 
contract  has  been  explained  as  follows : 

"From  the  standpoint  of  the  employer  the  renewable  term  plan  has 
the  advantage  of  covering  these  insurances  at  the  lowest  possible  cost 
during  the  period  in  which  the  employer  desires  the  coverage,  namely, 
during  continuance  of  employment.  Teint  iii&aiiai»ce  has  the  further 
merit  of  not  involving  surrender  values,  or  causing  the  employer  to  pay 
the  extra  sum  required  on  the  whole  life  level  premium  plan,  when  it  is 
a  foregone  conclusion  that  in  many  cases  the  employment  will  be  only 
temporary.  While  the  individuals  in  any  one  group  on  the  renewable 
term  plan  will  of  course  be  rated  each  year  at  a  successively  higher  rate, 
it  does  not  necessarily  follow  that  the  aggregate  rate  of  the  group  will 
increase  materially.  Conditions  of  active  employment  in  themselves 
require  certain  age  distributions  which  practically  assure  an  aggregate 
premium  on  the  term  basis  which  will  vary  within  narrow  limits  from 
year  to  year."^* 

"The  National  Convention  of  Insurance  Commissioners  have  attempted  to 
standardize  the  group  life  insurance  contract  by  the  recommendation  of  certain 
standard  provisions  and  the  adoption  of  the  following  definition  of  group  life 
insurance : 

"Group  life  Insurance  is  the  form  of  life  insurance  covering  not  less  than  fifty 
employees,  with  or  without  medical  examination,  written  under  a  policy  issued  to 
the  employer,  the  premium  on  which  is  to  be  paid  by  the  employer  or  by  the 
employer  or  employees  jointly,  and  insuring  only  all  of  his  employees,  or  all  of  any 
c-luss  or  classes  thereof  determined  by  conditions  pertaining  to  the  emplovment 
lor  amounts  of  insurance  based  upon  some  plan  which  will  preclude  individual 
selection  for  the  benefit  of  persons  other  than  the  employer,  provided  however. 
that  when  the  premium  is  to  be  paid  by  the  employer  and  employee  jointly  and 
the  benefits  of  the  policy  are  offered  to  all  eligible  employees,  not  less  than  seventy- 
five  per  cent  of  such  employees  may  be  so  insured." 

"William  J.  Graham.  "Group  Insurance"  Transactions  of  the  Actuarial  Society 
of  America,  1916,  Vol.  XVII,  Part  II,  No.  56,  p.  267. 


503 

Group  life  policies  may  be  participating  or  non-participating^  that 
is,  they  may  or  may  not  provide  for  the  distribution  of  dividends  to  the 
policyholder  (the  employer).  In  the  non-participating  policies  the 
insurance  company  "guarantees  the  rate"  for  a  term  of  years,  usually 
five  or  ten  but  sometimes  twenty/^  that  is,  the  company  guarantees,  in 
effect,  that  the  premium  charged  annually  or  at  other  intervals  shall  not 
exceed  a  sum  agreed  upon  between  the  company  and  the  policyholder. 
At  the  end  of  the  term  of  years  specified  the  insurance  company  may, 
if  it  sees  fit,  readjust  the  premium,  increasing  or  decreasing  it  as  ex- 
perience with  the  risk  and  other  considerations  may  warrant.  In 
participating  policies  the  company  may  "guarantee  its  gross  rate  in 
perpetuity,  adjustments  to  experience  being  effected  by  the  payment  of 
dividends,"^®  or  it  may  provide  as  in  the  non-participating  policies  for  a 
periodical  readjustment  of  rates.  Some  group  life  policies  are  renew- 
able annually  at  the  option  of  the  employer  for  50  or  more  years^  subject 
only  to  the  right  of  the  insurance  company,  in  policies  where  the  right 
is  reserved,  to  revise  the  premiums  at  the  end  of  the  guarantee  period 
agreed  upon;  other  policies  contain  no  time  limitation  on  the  renewal 
privilege.^^  In  either  case  the  employer  may,  in  effect,  cancel  the  con- 
tract at  will  on  any  anniversary  by  simply  discontinuing  the  payment  of 
premiums. 

The  advantage  of  the  guaranteed  premium  rate  and  the  renewal 
privilege  to  the  employer  is  that  it  enables  him  to  make  long-time  cal- 
culations with  respect  to  his  group  insurance  costs.  Provisions  of  this 
kind  are  essential  aids  to  the  salesman  of  group  life  insurance  for  an 
employer  may  reasonably  feel  that  it  would  take  several  years  to  demon- 
strate conclusively  the  value  of  group  insurance  as  a  means  of  develop- 
ing good-will  and  increased  efficiency  among  his  employees. 

The  right  of  the  employer  to  discontinue  the  policy  at  will  on  any 
anniversary  permits  him  to  drop  group  life  insurance  altogether  if  he 
thinks  that  it  is  not  worth  its  cost  or  to  substitute  a  cheaper  or  better 
policy  for  the  one  he  holds  whenever  a  cheaper  or  better  policy  appears 
on  the  market.  This  possibility  has  led  insurance  companies  writing 
group  insurance  to  scale  down  rates  "voluntarily"  in  a  considerable  num- 
ber of  cases  on  group  policies  outstanding  even  though  the  readjustment 
anniversary  of  the  policy  had  not  been  reached.  This  action  is  perhaps 
one  of  the  factors  responsible  for  the  very  small  percentage  of  cancel- 
lations among  group  life  insurance  policies.^^ 

In  its  details  the  group  life  insurance  policy  is  similar  to  life  in- 
surance policies  issued  to  individuals  except  where  special  provisions  are 
necessary  to  adjust  the  contract  to  the  group  plan. 

^5  Edward  B.  Morris,  paper  cited  above,  p.  156. 

"Ralph  H.  Blanchard  in  chapter  on  "Group  Insurance"  in  Huebner's  Life 
Insurance,  p.  307. 

"Edward  B.  Morris,  paper  cited  above,  states,  pp.  158-161,  that  as  far  as  he 
has  been  able  to  learn  "no  company  actually  provides  for  cancellation  inside  of 
fifty  years"  and  that  "some  of  the  companies  do  not  even  limit  the  contract  in  this 
respect."  Sample  policies  submitted  to  the  Commission  by  some  of  the  companies 
writing  group  life  insurance  support  this  statement. 

18  Edward  B.  Morris,  paper  cited  above,  remarks,  on  page  157,  that  it  is  "sur- 
prising what  a  relatively  small  number  of  group  contracts  have  been  cancelled  by 
the  employer"  and  states  that  of  some  300  group  policies  issued  by  the  Travelers 
Insurance  Company  up  to  the  time  at  which  he  wrote  "but  two  contracts  have  been 
discontinued  and  these  for  reasons  which  have  no  bearing  on  the  desirability  of 
the  insurance." 


504 

"One  contract,  or  group  policy,  is  issued  to  the  employer,  which 
makes  reference  to  necessary  supporting  detail  of  each  life  covered,  con- 
tains schedules  of  rates — and  where  other  than  term,  schedules  of  loan 
and  surrender  values — for  each  age,  and  otherwise  conforms  to  provisions 
for  similar  insurances  on  individual  lives.  Supplementary  certificates 
of  insurance,  commonly  issued  to  each  member  of  the  group,  state  the 
fact  of  the  insurance,  the  name  of  the  individual  insured,  the  amount  of 
the  insurance,  the  name  of  the  beneficiary,,  and  the  conditions  under 
which  the  insured  continues  in  force/^^^ 

The  following  is  an  outline  of  the  principal  provisions  of  the  group 
life  insurance  policy  used  by  one  company  which  writes  group  life  insur- 
ance in  Illinois.  The  outline  is  reproduced  exactly  as  it  was  furnished 
the  Commission  by  the  insurance  company  except  that  the  name  of  the 
company  is  omitted  and  the  word  "Company'^  inserted  instead  of  it. 

Group  Life  Insurance. 

a  brief  outline  of  the  principal  provisions  of  the  policy. 

Plan. — There  must  be  determined  upon  some  general  plan  of  in- 
surance based  upon  salary,  length  of  service,  age  or  other  general  con- 
dition. The  insurance  may  be  arranged  to  increase  automatically  at 
stated  intervals,  on  account  of  lengthened  term  of  service,  or  on  account 
of  increase  of  salary.  No  medical  examination  of  the  persons  insured  is 
required. 

Application. — An  application  is  made  on  a  blank  provided  by  the 
company,  in  which  is  set  out  the  plan  determined  upon.  On  anothei 
blank  are  set  down  the  name,  address,  residence,  sex,  occupation,  length 
of  employment  of  each  person  to  be  insured,  the  initial  amount  of  insur- 
ance, and  the  name  and  relationship  of  the  beneficiary. 

Policy. — One  policy  is  issued  to  the  employer  and  attached  is  a  list 
of  employees  insured  and  amount  carried  for  each.  The  insurance  for 
men  and  women  is  precisely  the  same. 

Certificate. — A  certificate  is  issued  by  the  insurance  company,  to 
each  person  insured,  stating  the  amount  of  his  or  her  insurance  and  the 
name  of  the  beneficiary.  It  states  that  the  insurance  will  only  be  paid 
in  case  death  occurs  while  the  insured  is  in  the  employ  of  the  employer 
securing  the  insurance. 

Premium. — The  premium  is  payable  monthly,  but, if  desired,  it 
may  be  arranged  to  be  paid  yearly,  half  or  quarter  yearly.  It  is  the  sum 
of  the  individual  premiums  computed  according  to  a  schedule  embodied 
in  the  policy. 

Period  of  grace. — Thirty-one  days'  grace  are  granted  the  employer 
for  payment  of  each  premium  after  the  first. 

Policy  renewable. — If  the  policy  is  issued  on  the  One-year  Term 
plan,  the  employer  may  renew  it  each  year  at  rates  increasing  with  the 
ages,  but  the  company  guarantees  that  schedule  of  rates  shall  not  be 
changed  for  five  years. 

Insurance — how  payable. — At  death  insurance  is  payable  to  bene- 
ficiary designed  by  insured. 

"William  J.  Graham,  paper  cited  above,  p.  267. 


J 


505 

Dwahility  benefits. — Should  an  employee  become  fully  and  perman- 
ently disabled  before  attaining  the  age  of  60  years,  no  further  premiuin 
is  payable  in  respect  of  him;  his  insurance  matures  and  the  Company 
will  pay  the  amount  of  it  in  installments,  with  interest,  over  a  period  of 
time,  and  should  he  die  before  they  are  all  paid,  will  pay  the  remaining 
installments  to  his  beneficiary. 

Mistatement  of  age. — Correction  to  be  made  in  amount  of  premium 
for  error  caused  by  mistatement  of  age  of  an  insured,  but  the  amount 
of  insurance  payable  to  the  beneficiary  remains  unchanged. 

Insurance  to  he  discontinued. — Employer  to  report  names  of  persons 
upon  whom  insurance  is  to  be  discontinued,  such  discontinuance  to  take 
effect  on  the  first  day  of  the  month  after  receipt  of  such  notice.  If 
premiums  are  payable  otherwise  than  monthly  all  unearned  premiums 
paid  on  such  discontinued  insurance  will  be  refunded  to  the  employer. 

Insurance  of  new  employees. — jN'ew  employees  may,  from  time  to 
time,  be  embraced  in  the  policy  on  the  same  basis  on  which  the  insurance 
w^as  originally  issued. 

Military  or  naval  service. — If  any  insured  engages  in  military  or 
naval  service  in  time  of  war,  his  insurance  ceases,  but  within  thirty-one 
days  thereafter  he  may  have  issued  to  him  a  separate  policy,  in  certain 
forms,  on  paying  the  premium  applicable  to  him. 

Change  of  beneficiary. — Any  insured  may  change  the  beneficiary  to 
receive  his  or  her  insurance. 

Participation. — The  policy  is  a  participating  one  and  the  company 
will  annually  ascertain  and  apportion  any  devisable  surplus  accruing  to 
the  individual  insurances  under  the  policy  and  will  pay  same  in  cash  to 
the  employer,  or,  if  desired,  apply  in  reduction  of  any  premium  then 
due. 

The  above  outline  is  in  large  part  self-explanatory  and  comment  and 
additional  explanation  will  be  made  only  where  necessary. 

The  amount  for  which  a  given  employee  is  insured  is  usually  either 
the  amount  of  a  j^ear's  wages  or  salary,  with  a  maximum  limit  of  from 
$3,000  to  $5,000,2^  or  a  scheduled  sum  which  increases  by  stipulated 
increments  with  length  of  service.  Sometimes,  however,  the  amount  of 
insurance  is  a  flat  sum,  as,  for  example,  $1,000,  which  applies  to  all 
employees  alike,  regardless  of  yearly  earnings  or  length  of  service,  and 
sometimes  it  varies  according  to  sex  or  marital  condition. 

The  plan  under  which  the  insurance  of  the  employee  increases  with 
length  of  service  is  illustrated  by  the  following  schedule  taken  from  a 
statement  made  to  the  Commission  by  an  Illinois  employer : 

For  employment   less   than    3    months No  insurance 

For  employment  3  months  and  less  than  1  year I    500 

For  employment   1  year  and  less  than   2  years 600 

For  employment  2  years  and  less  than  3  years 700 

For  employment  3  years  and  less  than  4  years 800 

For  employment  4  years  and  less  than  5  years 900 

For  employment  5  years  and  less  than  6  years 1,000 

For  employment  6  years  and  less  than  7  j^ears 1,100 

For  employment  7  years  and  over 1,200   (maximum) 

Some  of  the  schedules  used  by  other  employers  in  Illinois  who  pro- 
vide group  life  insurance  on  the  length  of  service  basis  vary  from  the 

^  Office  employees,  foremen  and  superintendents  and  even  general  officers  of  a 
corporation  may  be  covered  by  the  group  insurance  plan. 


606 

foregoing  schedule  in  the  minimum  length  of  service  accepted  the  length 
of  time  required  to  reach  the  maximum  amount  of  insurance  as  entitling 
an  employee  to  insurance,  and  the  amount  of  the  initial  insurance.  Of 
16  employers  reporting  the  provision  of  insurance  on  the  length  of 
service  basis,  one  reported  a  minimum  length  of  service  requirement  of 
30  days,  one  a  requirement  of  one  month,  7  a  requirement  of  3  months, 
one  a  requirement  of  4  months  and  a  6  a  requirement  of  6  months. 
The  initial  insurance  provided  employees  was  reported  by  14  employers ; 
nine  start  the  insurance  for  their  employees  at  $500,  two  at  $300,  one 
at  $250,  one  at  $200,  and  one  at  $150.  The  maximum  insurance  pro- 
vided employees  on  the  length  of  service  basis  was  reported  by  13  em- 
ployers, 9  of  whom  reported  a  maximum  of  $1,000,  one  each  a  maximum, 
respectively,  of  $2,000,  $1,500  and  $1,200  and  one  a  maximum  limited 
to  the  salary  or  wages  of  the  employee.  The  maximum  could  be  attained 
in  the  greater  number  of  cases  in  5  years  but  in  some  the  time  required 
was  6  or  7  years. 

It  was  indicated  above  that  16  of  the  24  employers  who  furnished 
the  Commission  statements  concerning  the  group  life  insurance  with 
which  they  provide  their  employees  have  adopted  the  length  of  service 
basis  as  the  method  of  determining  the  amount  of  insurance  for  the 
individual  employee.  Four  of  the  remaining  employers  reported  that 
they  insure  their  employees  for  the  amount  of  a  year's  wages  and  one 
that  it  insures  its  employees  for  a  fixed  sum — the  amount  not  stated. 
Three  employers  failed  to  make  definite  statement  in  the  matter. 

The  argument  in  favor  of  the  length  of  service  basis  of  determining 
the  amount  of  an  employee's  insurance  is  obvious.  Those  who  favor  the 
adjustment  of  the  amount  of  insurance  according  to  the  wages  of  the 
employee,  with  a  maximum  limit  of  $3,000  or  $5,000,  contend,  however, 
that  their  plan  is  more  satisfactory  than  the  first  mentioned  plan. 

"It  takes  automatic  account  of  all  changes  in  the  payroll  in  the 
way  of  increases  or  decreases,  and  there  is  no  discrimination  between 
individuals  other  than  that  which  already  naturally  exists.  All  em- 
ployees are  insured  according  to  a  standard  already  in  existence  which 
is  familiar  to  them.  The  salary  received  by  an  employee  is  based  not 
only  on  the  quality  and  character  of  his  service  but  upon  length  of 
service  as  well.  When  a  new  employee  is  engaged  at  the  same  salary  as 
that  paid  to  an  old  employee,  it  is  a  fair  assumption  that  the  new 
employee  is  a  more  valuable  one."^^ 

The  statement  in  the  outline  that  "no  medical  examination  of  the 

persons  insured  is  required"^^  can  be  explained  best  by  describing  the 

method  by  which  the  groups  covered  by  group  life  insurance  are  selected. 

This  has  been  done  by  an  authority  on  group  life  insurance  as  follows: 

^  "The  cardinal  principles  of  group  selection  are,  roughly : 

(a)  To  obtain  a  body  of  risks  selected  for  purposes  requiring  physi- 
cal and  moral  fitness ; 

(b)  To  see  that  the  group  is  acceptable  as  a  whole,  or  in  classes  not 
inferior  in  point  of  insurability  to  the  group  as  a  whole ; 

»*  Ralph  Barnard  Trousdale,  of  the  Equitable  Life  Assurance  Society,  Annals 
American  Academy  Political  and  Social -Science,  Vol.  70,  pp.  94-95,  March,  1917. 

"  Some  companies  have  required  a  medical  examination  for  new  employees 
added  to  the  orit^inal  group.  See  Ralph  H.  Blanchard's  chapter  on  "Group  Insur- 
ance" in  Huebner's  Life  Insurance,  p.  305. 


507 

(c)  To  grade  the  risk  properly  at  the  standard  rate  or  at  a  com- 
mensurate extra  premium  rate  for  acceptable  additional  hazard. 

"The  mere  statement  of  these  three  general  subdivisions  governing 
selection  narrows  down  the  acceptances  of  groups  without  medical  exam- 
ination closely  to  (a)  employees  of  one  employer;  (b)  where  all  or  sub- 
stantially all  lives  must  be  included  in  the  group  except  as  certain  whole 
departments  or  sexes  or  probationers  are  excluded;  and  (c)  where  the 
grade  of  employees  and  the  occupational  and  incidental  hazards  measure 
up  to  required  standards  or  else  can  be  adjusted  by  commensurate  extra 
premium  ratings  within  the  range  of  reasonable  additions  to  the  stand- 
ard rates. 

"Careful  inspection  of  each  group  is  made  to  determine  the  facts 
as  above  outlined.  Such  inspections  include  investigations  of  employees 
and  plants.  Sex,  nationality,  wage,  sobriety  and  requirements  for  em- 
ployment are  important  personal  factors.  Trade  dusts  and  trade  dis- 
eases are  important  in  character  and  in  ratio  to  the  number  of  the  whole 
so  exposed.  The  buildings  and  surroundings  are  studied  with  view  to 
proper  air,  sanitation,  hygiene,  pure  drinking  water,  etc.,  and  with  refer- 
ence to  accident  and  panic  hazards. 

"Group  insurance  must  carefully  guard  against  adverse  individual 
selection.  Hence  the  necessity  for  insuring  the  group  on  a  basis  which 
does  not  leave  with  the  individual  the  power  to  decide  whether  or  not 
he  or  she  shall  enter  the  group.  This  militates  against  the  acceptance 
of  a  group  in  which  the  insurance  is  paid  for  by  the  individual  employee. 

"An}^  attempt  to  apply  group  insurance  to  less  than  the  whole  avail- 
able class  to  whom  it  is  offered  involves  the  danger  of  adverse  selection 
entering  to  the  degree  of  making  the  whole  uninsurable.  An  even  more 
vital  point  of  insurability  would  be  involved  if  individuals  were  privi- 
leged to  choose  to  continue  in  the  group  or  not.  Again  the  group  plan 
contemplates  the  elimination  of  individual  solicitation.  Where  indi- 
vidual action  is  necessary  to  bring  the  whole  to  a  point  of  insurability, 
a  soliciting  cost  is  introduced  that  militates  against  the  practical  applica- 
tion of  the  group  idea.  For  these  reasons  group  insurance  is  in  a  large 
degree  restricted  to  the  insurance  of  employees  of  one  employer  where 
the  employer  pays  the  entire  premium.^^^^ 

The  minimum  number  of  individuals  who  will  be  accepted  without 
medical  examination  for  group  life  insurance  has  commonly  been  fixed 
at  100  by  the  life  insurance  writing  group  insurance  although  in  one  or 
two  states  a  minimum  of  50  lives  has  been  recognized-*  and  this  mini- 
mum has  been  accepted  as  sufficient  by  the  National  Convention  of 
Insurance  Commissioners.  In  practice  group  life  insurance  has  not 
always  been  restricted  to  groups  complying  with^  the  minimum  require- 
ments as  to  numbers. 

"As  a  matter  of  fact,  group  policies  are  issued  on  less  than  one 
hundred  lives  by  giving  a  modified  form  of  medical  examination.  This 
modified  examination  increases  in  severity  as  the  group  shrinks  from  the 
full  hundred  until  full  medical  examination  and  rigid  judgment  of  the 
same  is  accorded  all  risks  where  the  number  decreases  to  the  arbitrary 

23  William  J.  Graham,  paper  cited  above,  pp.  264-265. 

2*  H.  Pierson  Hammond,  Life  Insurance  in  Groups,  1912-17,  address  before 
National  Convention  of  Insurance  Commissioners,  August  28,  1917,  reprinted  in  The 
Economic  World,  July  13,  1918,  p.  57. 


508 

minimum — usually  twenty-five  lives — required  for  any  form  of  group 
or  blanket  insurances.  Necessarily  such  modified  groups  may  exclude 
one  or  more  lives  upon  the  medical  showing."^^ 

•  The  number  of  employees  in  a  group  will  necessarily  vary  from  time 
to  time  as  deaths,  withdrawals  and  additions  occur  and  the  group  life 
insurance  policy  accordingly  makes  provision  for  readjusting  the  pre- 
mium to  compensate  for  the  changes  in  numbers,  ages,  amounts  of  insur- 
ance for  individual  employees,  and  other  details.  As  the  outline  states, 
the  premium  paid  by  the  employer  "^is  the  sum  of  the  individual  pre- 
miums computed  according  to  a  schedule  embodied  in  the  policy.'^ 

Employees  for  whom  group  life  insurance  is  purchased  are  given 
the  right  of  naming  their  beneficiaries.  Employers  sometimes  ask  insur- 
ance companies  to  name  them  as  the  beneficiaries  of  the  employees  for 
whom  they  purchase  insurance  in  order  that  they  may  administer  claims 
when  they  arise  but  insurance  companies  do  not  consider  it  good  practice 
to  grant  such  requests  because  of  the  possible  moral  hazards  involved  in 
some  cases  and  the  legal  questions  of  insurable  interest  which  might 
arise.  ^*^  The  insurance  companies,  however,  commonly  send  the  checks 
or  drafts  used  in  the  payment  of  claims  to  the  employer  for  distribution 
by  him  to  the  beneficiaries. 

The  insurance  payable  on  the  death  of  an  employee  may  be  paid  to 
his  beneficiary  either  in  a  lump  sum  or  in  installments  as  is  the  case 
with  life  insurance  on  individual  policies.  When  payable  in  installments 
payments  are  often  spread  over  a  period  of  twelve  months,  instead  of 
over  a  longer  period,  with  the  idea  of  continuing  the  employee's  wages, 
or  a  considerable  portion  of  them,  after  his  death  until  his  dependents 
have  had  an  opportunity  to  arrange  for  their  own  support. 

The  disability  benefits  for  which  some  group  life  insurance  policies 
provide  are  similar  to  those  which  have  been  introduced  in  recent  years 
in  many  life  insurance  policies  sold  to  individuals.  The  following  dis- 
ability clause  from  a  sample  group  life  policy  submitted  to  the  Commis- 
sion by  one  of  the  insurance  companies  which  writes  group  life  insurance 
in  Illinois  is  fairly  typical: 

Si.^  months  after  proof  is  received  at  the  Home  Office  of  the  com- 
pany (that  is,  the  insurance  company)  that  any  person  insured  hereunder 
has  become  wholly,  continuously  and  permanently  disabled  and  will  for 
life  be  unable  to  perform  any  work  or  conduct  any  business  for  com- 
pensation or  profit,  provided  that  such  disability  occurs  while  the  insur- 
ance upon  such  life  is  in  full  force  and  before  'the  insured  has  attained 
the  age  of  sixty  years,  then,  in  lieu  of  all  other  benefits  herein  provided, 
the  company  will  waive  further  payment  of  premium  for  the  insurance 
upon  such  life  and  will  pay  immediate  disability  benefits.  The  mode 
of  settlement  shall  be  that  one  of  the  following  optional  methods  that 
shall  be  designated  by  the  employer. 

Fir^f.— Payment  of  the  full  sum  insured  in  installments  to  the 
person  disabled.  The  installments  shall  be  payable  monthly,  quarterly, 
semi-annually,  or  annually,  and  shall  cover  a  period  of  fivej  ten,  fifteen 
or  twenty  years,  the  first  payment  to  be  made  immediately.  Any  install- 
ments  remaining  unpaid  at  the  death  of  the  insured  shall  be  payable 

"William  J.  Graham,  paper  cited,  Note  1,  p.  10,  p    265 
"William  J.  Graham,  paper  cited  above,  p.  269. 


509 


as  they  become  due  to  the  beneficiary  designated  in  the  application  for 
this  policy,  who  shall  have  the  right  to  commute  such  remaining  install- 
ments into  one  sum  on  the  basis  of  interest  at  three  and  one-half  per  cent 
(31/2%)  per  annum. 

TABLE  SHOWIJ^G  THE  AMOUNT   OF  INSTALLMENT  AND  TERM   FOR  WHICH 

IT  WILL  BE  PAID. 

These  amounts  are  based  on  a  single  payment  of  one  thousand  dol- 
lars of  insurance.  Installments  payable  for  insurance  of  a  greater  or 
less  amount  shall  be  proportionate. 


Years. 

Annually. 

Semi- 
annually. 

Quarterly. 

Monthly. 

5 

$214. 00 

116.00 

84.00 

68.00 

$107.00 
58.00 
42.00 
34.00 

$53.50 
29.00 
21.00 
17.00 

$17.83 

10 

9.67 

15 

7.00 

20 

5.67 

When  an  employee  terminates  his  employment  the  insurance  com- 
pany, upon  receiving  notice  from  the  employer,  will  discontinue  the  in- 
surance of  the  employee  and  credit  the  employer  with  the  unearned 
portion  of  any  premium  paid  on  account  of  the  employee.  If  an  em- 
ployee is  temporarily  absent  from  duty  because  of  illness  or  on  a  leave 
of  absence  granted  by  his  employer  the  latter  usually  continues  the 
insurance  of  the  employee.  If  an  employee  is  "laid  of!"  temporarily 
because  of  lack  of  work  the  employer  may  be  or  may  not  continue  the 
insurance.  Illinois  employers  who  have  adopted  group  life  insurance 
have  done  so,  with  few  exceptions,  during  the  present  period  of  pros- 
perity and  most  of  them  have  had  no  occasion  to  adopt  a  settled  practice 
with  respect  to  the  carrying  of  insurance  for  emploj^ees  temporarily  idle 
because  of  lack  of  work.  The  policies  which  employers  adopt  in  this 
matter  when  the  occasion  for  decision  does  arise  in  the  future  will  be  of 
great*  importance  in  determining  the  value  of  group  life  insurance  as  an 
agency  for  meeting  the  need  of  the  wage-earner  for  insurance. 

When  an  employee  retires  from  employment  because  of  old  age  or 
because  of  disability  not  covered  by  a  disability  clause  in  the  group 
policy  the  employer  may,  if  he  desires,  under  the  terms  of  some  group 
policies^^  continue  the  insurance  of  the  employee. 

The  privilege  of  applying  to  the  insurance  company  writing  the 
group  policy  for  individual  insurance  without  medical  examination  may 
be  given  employees  discontinuing  employment  if  the  employer  so  desires. 
Usually  the  privilege  must  be  exercised  within  31  days  after  the  termin- 
ation of  employment.  The  employee  is  usually  permitted  to  select  any 
type  of  policy  except  a  term  policy.  He  must,  however,  pay  the  regular 
rate  for  his  attained  age  and  the  conversation  privilege  is  therefore  of 
no  value  to  him  except  as  a  means  of  escaping  a  medical  examination 
which  might  debar  him  from  insurance.  Most  of  the  employers  who 
presented  data  to  the  Commission  with  respect  to  group  life  insurance 
plans  which  they  had  adopted  stated  that  their  policies  contained  pro- 

2^  This  may  be  possible  under  all  group  life  insurance  policies  now  in  use  but 
the  absence  of  complete  data  forbids  a  positive  statement  to  that  effect. 


510 

visions  permitting  employees  withdrawing  from  service  to  take  out 
individual  life  insurance  policies  without  medical  examination.  The 
data  show,  however,  that  very  few  employees  have  availed  themselves 
of  this  privilege.  One  employer  explained  that  although  "employees 
discharged  or  leaving  the  firm  would  be  entitled  to  individual  policies 
without  medical  examination"  the  firm  had  not  "pushed  this  feature." 
Illinois  experience  with  the  conversion  privilege  seems  to  be  in  line  with 
the  experience  in  other  states. 

(4)  The  cost  of  group  life  insurance. — Group  insurance,  as  was 
said  in  the  opening  statement  of  this  study,  is  essentially  insurance  at 
wholesale.  It  is  insurance  in  quantity  lots  which  can  be  sold  at  quantity 
prices  because  of  the  elimination  or  reduction  of  the  expenses  which 
have  to  be  met  when  insurance  is  sold  in  the  ordinary  way  on  individual 
policies. 

"Large  economies  are  achieved  under  the  group  system.  Agency 
work  is  reduced  by  being  centralized.  Individual  members  of  the  group 
are  not  solicited.  Commissions  and  renewals  are  fixed  at  about  one- 
third  of  the  usual  rate  for  the  same  form  of  individual  insurance.  The 
elimination  of  all  accounting,  correspondence  and  premium  collection 
with  the  individual  greatly  reduces  the  cost  of  caring  for  the  business. 
All  accounting  is  centralized  in  the  one  periodical  statement  to  the  em- 
ployer. In  this  statement  the  changes  occurring  during  the  period  are 
carried  forward  in  total  only  and  without  detailed  restatement."^^ 

The  elimination,  in  most  cases,  of  the  expense  of  individual  medical 
examination  of  the  candidates  for  insurance  should  also  be  mentioned 
for  this  is  an  important  item  in  the  first-year  expenses  on  individual 
insurance  policies. 

Another  reason  for  the  comparatively  low  rates  at  which  group  life 
insurance  is  sold  is  the  expected  favorable  mortality  resulting  from  the 
care  used  in  inspecting  groups  for  whom  group  insurance  is  sought,"^ 
and  the  relatively  high  standards  of  health  and  physical  fitness  fre- 
quently demanded  by  the  nature  of  the  employment. 

"The  employer  is  vitally  interested  in  the  physical  selection  of  his 
employees  and  there  is  a  growing  disposition  among  progressive  estab- 
lishments to  add  some  form  of  medical  examination  to  the  usual  re- 
quirements. In  certain  establishments  this  medical  examination  far 
exceeds  in  comprehensiveness  the  physical  examination  for  life  insur- 
ance, including  such  important  points  as  hearing,  eyesight  and  careful 
examination  of  teeth. 

Even  where  there  is  no  medical  examination  of  the  applicant  for 
employment  there  is  always  a  shrewd  and  more  or  less  unconscious  phy- 

» William  J.  Graham,  paper  cited,  p.  270.  Edward  B.  Morris,  paper  cited 
above,  p.  153,  explains  that  group  life  insurance  is  usually  sold  by  salaried  specialists 
In  group  insurance  from  the  home  office  of  the  insurance  company  and  that  the 
commissions  which  have  been  paid  "have  hardly  averaged  as  high  as  commissions 
for  renewals  on  life  policies — perhaps  5  per  cent." 

"  Ralph  H.  Blanchard  in  chapter  on  "Group  Insurance"  in  Huebner's  Life  In- 
surance, p.  306.  A  study  of  the  "Joint  Mortality  Experience  of  the  Aetna  Life  and 
Travelers  Insurance  Companies  on  Group  Policies,"  by  E.  E.  Cammack  and  E.  B. 
Morris,  will  be  found  in  a  recent  number  of  the  Transactions  of  the  Actuarial 
Society  of  America.  This  study,  a  copy  of  which  was  furnished  the  Commission 
in  advance  of  publication,  indicates  that  the  actual  mortality  has  generally  been 
favorable  in  groups  in  some  industries  and  unfavorable  in  groups  in  certain  other 
industries. 


511 

sical  size-up  by  the  employer.  Employment  departments  select  healthy 
people  in  order  to  get  the  work  done  properly.  The  physically  inferior 
have  smaller  chance  of  employment  in  modern  industries  than  the  physi- 
cally strong.  Futhermore,  if  employed,  the  test  during  the  first  few 
days  of  competition  with  the  physically  strong  serves  to  adjust  the  em- 
ployei'^s  misjudgment  where  the  risk  has  been  over-rated  on  appear- 
ance."^° 

The  premium  rates  for  group  life  insurance  on  the  lives  of  em- 
ployees of  a  given  age  issued  on  a  given  type  of  policy  will  vary  from 
establishment  to  establishment  according  to  the  nature  of  the  group 
hazards,  occupational  and  environmental,  which  are  believed  tp  influence 
the  mortality  within  the  group.  It  is  said  that  premium  rates  also  vary 
somewhat  according  to  the  exigencies  of  competition  between  the  insur- 
ance companies  which  write  group  life  insurance. 

The  following  table,  taken  from  a  sample  policy  furnished  the  Com- 
mission by  an  insurance  company  which  writes  group  life  insurance  on 
the  non-participating  basis,  shows  the  group  rates  to  be  charged  according 
to  the  terms  of  the  policy,  for  employees  for  each  age  from  16  to  95, 
inclusive : 

TABLE  OF  TERM  PREMIUM  RATES  FOR  ONE  THOUSAND  DOLLARS  OP 
INSURANCE.  RATES  FOR  INSURANCE  OP  A  GREATER  OR  LESS 
AMOUNT  WILL  BE  PROPORTIONATE. 


Age  nearest  birthday. 


Annual 
premium. 


Age 

nearest 

birthday. 


Annual 
premium. 


Age 

nearest 

birthday. 


Annual 
premium, 


Age 

nearest 

birthday. 


Annual 
premium. 


16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 


$8.16 

36 

$  9.00 

56 

$  22.89 

76 

8.20 

37 

9.12 

57 

24.52 

77 

8.24 

38 

9.26 

58 

26.38 

78 

8.28 

39 

9.43 

59 

28.48 

79 

8.31 

40 

9.64 

60 

30.92 

80 

8.36 

41 

9.90 

61 

33.71 

81 

8.39 

42 

10.22 

62 

36.86 

82 

8.43 

43 

10.^4 

63 

40.35 

83 

8.48 

44 

11.13 

64 

44.19 

84 

8.51 

45 

11.67 

65 

48.38 

85 

8.56 

46 

12.25 

66 

52.92 

86 

8.59 

47 

12.88 

67 

57.81 

87 

8.63 

48 

13.57 

68 

63.05 

88 

8.65 

49 

14.37 

69 

68.87 

89 

8.67 

50 

15.  26 

70 

72.30 

90 

8.70 

51 

16.31 

71 

78.24 

91 

8.73 

52 

17.47 

72 

84.64 

92 

8.78 

53 

18.70 

73 

91.61 

93 

8.84 

54 

19.98 

74 

99.20 

94 

8.91 

55 

21.37 

75 

107.46 

95 

$116.31 
126. 09 
136.  56 
147. 85 
160. 19 
173. 46 
187.  78 
203. 15 
219.  79 
237. 60 
256.69 
277. 18 
299.07 
321.  76 
345  86 
371. 35 
398. 24 
426. 65 
456.33 
487. 41 


It  is  not  possible  to  say,  on  the  basis  of  information  available  to  the 
Commission,  how  closely  the  above  rates  are  adhered  to  in  actual  practice 
by  the  company  publishing  them.  The  fact  that  these  group  rates  are 
actually  higher  for  the  ages  16  to  30  inclusive  and  46  to  57  inclusive 
than  the  rates  published  in  the  Unique  Chart  for  1917^^  for  individual, 

*»Wm.  J.  Graham,  paper  cited  above,  p.  272 

^  The  Unique  Comparative  Chart  of  Premium  Rates,  of  the  Regular  Life  In- 
surance Companies,  1917-18.  Sampson,  Dawe,  Boston,  Mass.  Some  of  the  rates 
shown  in  the  chart  for  the  individual  policies  mentioned  are  as  follows:  age  16, 
$7.79;  age  20,  $7.94;  age  25,  $8.82;  age  30,  $8.61;  age  35,  $9.23;  age  40,  $10.17; 
age  45,  $11.73;  age  46,  $12.19;  age  50,  $14.79;  age  55,  $20.69;  age  57,  $24.35;  age 
58,  $26.57. 


512 

non-participating,  renewable  and  convertible  one-year  term  policies 
issued  by  the  same  company  is  hardly  to  be  explained  by  the  inclusion 
of  a  disability  clause  in  the  group  policy  and  its  absence  in  the  individual 
policy.  It  seems  probable  that  the  rates  shown  in  the  table  are  designed 
to  apply  to  the  poorer  group  risks  accepted  by  the  insurance  company 
and  that  lower  rates  are  charged  for  the  better  risks.  Otherwise  there 
would  be  no  advantage  to  the  employer  in  purchasing  a  group  policy 
instead  of  individual  policies  for  his  employees  except  in  the  possibility 
of  covering  employees  who  might  be  excluded  by  the  individual  medical 
examinations  and  the  saving  of  more  or  less  clerical  work  and  labor  of 
supervision.  The  table  of  rates  is  included  in  this  discussion  not  be- 
cause it  stows  accurately  the  group  rates  usually  paid,  but  because  it 
illustrates  the  way  in  which  the  group  rate  is  obtained  and  the  way  in 
which  the  rates  on  individual  employees  increase  with  their  ages.  The 
rapid  increase  of  the  per  employee  cost  of  group  life  insurance  during 
certain  age  groups,  as,  for  example,  from  50  to  65,  is  a  fact  which  must 
be  borne  in  mind  in  discussing  the  merits  of  group  life  insurance  on  the 
one-year  renewable  term  plan  as  a  partial  solution  of  the  problem  of 
meeting  the  wage-earner^s  need  for  insurance. 

The  cost  of  group  life  insurance  is  frequently  stated  by  the  insur- 
ance companies  which  write  this  form  of  insurance  in  terms  of  a  per- 
centage of  the  employer's  payroll  or  a  percentage  of  the  total  amount 
of  insurance  purchased  for  the  group,  if  this  differs  from  the  amount 
of  the  payroll.  The  estimates  most  frequently  made  range  from  less 
than  one  to  one  and  a  quarter  per  cent  of  the  payroll  or  total  amount 
of  insurance. 

"For  preliminary  purposes,  and  before  the  foregoing  information 
(that  is,  information  concerning  details  of  the  group  risk)  is  available, 
the  rate  is  usually  quoted  as  one  dollar  per  month  for  each  thousand 
dollars  of  insurance.  On  a  percentage  basis,  this  w^ould  amount  to  a 
premium  of  1.2  per  cent  on  the  total  amount  of  insurance."^^ 

"A  very  satisfactory  group  plan  can  be  secured  for  approximately 
ll^  per  cent  of  gross  payroll.'^^^ 

"There  will  be  at  some  time  a  final  inventory  taken  of  each  em- 
ployee. Are  his  years  of  loyal  service  not  worth  a  charge  of  approxi- 
mately 1  per  cent  of  his  annual  wage,  to  provide  for  at  least  another 
year's  wage  to  his  wife  and  children  after  his  death  and  to  represent 
the  human  element  of  wear  and  tear?"^* 

"In  industrial  plants  policies  providing  insurance  for  one  year's 
wages  average  in  cost  less  than  1  per  cent  of  the  total  payroll."^^ 

"The  Equitable's  experience  with  many  group  risks  would  place 
the  gross  estimate  of  cost  of  approximately  1^4  per  cent.  In  the  past 
the  net  cost  has  approximated  1  per  cent  on  most  groups  of  standard 
occupation.     Translated  into  cost  per  1,000,  this  means  an  outlay  of  per- 

'"Ilalph  Barnard  Trousdale,  of  the  Equitable  Life  Assurance  Society,  article 
cited  above,  p.  95. 

"  Lawrence  C.  Wood,  representing  the  Equitable  Life  Assurance  Society,  Group 
Life  Insurance,  paper  prepared  for  the  Annual  Meeting  of  the  Natural  Gas  Associa- 
tio  of  America,  May  16,  1916,  p.  9. 

»*  The  Employer  and  the  Employee,  pamphlet  published  by  the  Travelers  Insur- 
ance Company,  p,  3. 

»»  Group  Insurance,  pamphlet  published  by  the  Aetna  Life  Insurance  Company, 
p.  4. 


513 

haps  from  80  cents  to  $1  a  month  for  most  groups.  The  Equitable 
Group  plan  is  a  participating  plan  and  premium  refunds  thus  far  paid 
back  to  the  employer  in  the  form  of  annual  dividends  have  substantially 
reduced  the  gross  premium  cost."^^ 

Another  estimate  places  the  average  cost  of  group  life  insurance, 
including,  presumably,  insurance  issued  on  the  basis  of  wages,  the  length 
of  service  basis  and  the  uniform  amount  basis,  at  "not  usually  over  two 
cents  per  employee  per  day/'^^ 

)^  (5)  Advantages  and  disadvantages  of  grouy  life  insurance. — The 
advantages  claimed  for  group  life  insurance  are  usually  stated  from  the 
point  of  view  of  the  employer  for  it  is  to  the  employer  that  the  appeal 
must  be  made  in  finding  purchasers  for  this  type  of  insurance.  The 
insurance  companies  make  the  appeal  on  two  grounds.  They  call  atten- 
tion, in  the  first  place,  t(3_the  common  lack  of  adequate  provision  or  of  | 
any,  provision  at  all,  for  life  insurance  among  wage-earners  and  urge 
resort  to  group  life  insurance  for  humanitarian  reasons.  The  insurance 
companies  contend,  in  the  second  place,  that  it  j)ajs  the  employer  as  a  ^ 
inatter  of  business,  without  any  regard  to  humanitarian  considerations, 
to  purchase  group  life  insurance  for  his  employees. 

Much  more  use  is  made  of  the  second  argument  than  of  the  first,     y 
Two  assertions  are  made  in  developing  this  argument :  first,  that  group 
life  insurance  reduces  the  labor  turnover  and  second  that  it  creates  or 
increases  good-will  for  the  employer  among  the  permanent  employees.    -■'_. 
The  effect  of  group  life  insurance  is  therefore  to  increase  the  efficiency 
of  employees  and  thus  to  pay  for  itself  in  increased  output. 

"It  may  be  properly  suggested  that  the  correct  instruction  to  the 
accountant,  when  group  insurance  is  purchased  by  the  employer,  no 
matter  what  the  motive  for  its  purchase  may  be,  is  ^debit  payroll  and 
credit  cash^  for  labor  or  service  have  been  received  and  cash  has  been 
paid  out."^^ 

"Group  insurance  is  viewed  as  an  expenditure  for  which  adequate 
returns  are  secured,  rather  than  as  an  expense.^'^^ 

"Group  insurance  attracts  the  desirable  classes  of  labor.  It  appeals 
particularly  to  married  men  with  families — the  less  migratory  class — 
and  from  ahnost  every  point  of  view  in  days  of  extreme  pressure  this  is 
the  most  satisfactory  class  of  men  to  carry  on  the  payroll.  But  what  is 
just  as  important,  group  insurance  helps  to  hold  labor.  Five  minutes  ^ 
consideration  of  the  plan  will  convince  and  employer  that  this  claim  can 
be  substantiated.  The  testimony  of  Aetna  group  insurance  policy- 
holders is  that  the  cost  is  more  than  offset  by  the  resulting  increase  in 
efficiency,  and  by  the  reduction  of  loss  involved  in  replacing  trained  and 
skilled  employees — men  accustomed  to  the  practice  and  work  of  the 
factory — by  new  and  untried  hands.'^*" 

"  Group  Insurance  at  a  Glance,  pamphlet  published  by  the  Equitable  Life  Assur- 
ance Society,  p.  2.  • 

""What  is  Group  Insurance?"  an  article  by  J.  A.  Peck,  reprinted  from  The 
American  Hatter  by  the  Travelers  Insurance  Company,  1918,  p.  3. 

"  The  Employer  and  the  Employee,  pamphlet  published  by  the  Travelers  Insur- 
ance Company,  p.   2. 

^  Group  Insurance  at  a  Glance,  pamphlet  published  by  the  Equitable  Life  As- 
surance Society,  p.  2. 

^**  Group  Insurance,  pamphlet  published  \>y  the  Aetna  Life  Insurance  Company, 
p.  3.     The  italics  are  by  the  present  writer. 

—33  H  I 


514 

The  claims  made  by  the  insurance  companies  for  the  efficacy  of 
group  life  insurance  as  a  means  of  increasing  efficiency  in  establishments 
making  use  of  the  plan  are  sustained  by  opinions  expressed  by  many 
employers  as  quoted  in  the  advertising  literature  of  the  insurance  com- 
panies. To  get  the  views  of  Illinois  employers  known  to  be  making  use 
of  group  life  insurance  the  Commission  included  a  question  relating  to 
the  effect  of  group  life  insurance  on  the  labor  turnover  in  the  question- 
naire which  it  sent  to  these  employers.  Replies  to  the  question  were 
received  from  twenty  employers.  Of  these  employers  six  stated  in 
substance  that  they  were  unable,  because  of  their  short  experience  with 
group  life  insurance  or  because  of  the  abnormal  labor  conditions  pre- 
vailing, to  speak  positively  one  way  or  the  other  of  the  effect  of  group 
life  insurance  on  the  labor  turnover;  seven  stated  in  substance  that,  so 
far  as  they  could  see,  group  life  insurance  had  had  no  appreciable  effect 
as  yet  on  the  labor  turnover ;  and  seven  thought  that  the  plan  had  been 
of  some  benefit  in  reducing  the  labor  turnover  or  that  it  would  prove  of 
some  benefit  in  this  direction  in  the  future.  On  the  whole  the  opinions 
expressed  by  the  Illinois  employers  above  mentioned  seem  inconclusive; 
they  merely  prove,  if  they  prove  anything,  that  group  life  insurance  has 
no  magic  power  to  produce  the  desired  results  instantaneously  or  to  over- 
come all  temptations  in  the  form  of  higher  wages,  shorter  hours  or 
purely  personal  considerations  that  lead  employees  to  leave  their  em- 
ployers and  seek  work  elsewhere. 

Several  of  the  employers  who  replied  to  the  question  with  respect 
^to  the  effect  of  group  life  insurance  on  the  labor  turnover  described  or 
discussed  the  attitude  of  their  employees  toward  the  plan.     The  follow- 
ing are  receipts  from  the  replies  of  these  employers. 

"We  consider  the  group  insurance  very  effective  among  the  Ameri- 
can class  of  help  but  rather  indifferent  among  the  foreign  element,  of 
which  we  employ  quite  a  number.^' 

"Employees  have  generally  shown  indifference  in  accepting  the 
policies,  (benefit  certificates),  and  in  a  few  cases  almost  a  refusal.  How- 
ever, we  have  faith  in  the  project  and  intend  to  continue  it  till  some- 
thing like  stable  conditions  are  resumed.^' 

"■As  a  rule  the  employee  and  especially  the  Trades  Union  employee 
has  not  and  does  not  take  kindly  to  any  proposition  even  though  offered 
in  the  best  of  faith  tending  to  benefit  his  condition  by  making  him  in- 
terested in  the  business  of  the  employer  either  by  the  distribution  of  a 
bonus,  percentage  of  profits,  or  otherwise.  As  soon  as  these  bonus 
systems  are  put  in  effect  the  employees  take  it  as  a  matter  of  course 
and  as  a  part  of  their  wages.  They  immediately  notify  their  fellow- 
workers  in  other  factories  and  members  of  the  union  in  general  and  the 
result  is  a  general  increase  in  wages  all  along  the  line  and  the  object  of 
the  benefit  sought  is  defeated ;  namely,  the  inducing  of  the  employee  to 
become  more  interested  in  the  production  end  of  the  husiness.     *     *     *. 

"Our  employees  are  largely  foreigners  and  while  we  believe  many  of 
them  appreciate  the  insurance  feature  there  are  others  who  do  not  regard 
it  in  the  light  of  any  value  to  themselves;  that  is,  they  would  probably 
leave  our  employ  for  the  addition  of  a  cent  or  two  per  hour  of  wage 


515 

increase,  going  to  a  factory  where  their  insurance  would  not  be  carried 
rather  than  remain  to  work  for  the  lower  wage." 

"When  this  insurance  was  first  presented  quite  a  few  (employees) 
were  suspicious  that  the  Company  was  trying  to  put  something  over  on 
them  (as  they  expressed  it)  etc.,  but  we  insisted  on  carrying  them  until 
we  could  prove  our  stand  and  as  the  first  man  to  die  was  the  principal 
objector  and  as  his  family  did  not  have  any  money  when  his  estate  was 
paid  the  amount  the  deceased  person  was  insured  for,  all  came  into  line, 
many  expressing  appreciation  of  what  the  Company  was  trying  to  do." 

Other  employers  stated  that  their  emloyees  were  "very  much  inter- 
ested" in  the  group  plan  or  "very  appreciative"  of  it. 

In  general  it  would  seem  fair  to  conclude,  on  the  basis  of  the  in- 
formation available  to  the  Commission,  that  the  experience  of  Illinois 
employers  with  group  life  insurance  has  been  too  brief  to  determine  the 
value  of  the  plan  as  an  antidote  for  "labor  unrest." 

If  we  turn  to  the  arguments  advanced  in  favor  of  group  life  insur- 
ance from  the  point  of  view  of  the  employee  we  find  that  there  are  two 
arguments  to  be  considered :  first,  that  group  life  insurance — now  com- 
monly paid  for  by  the  employer  alone — is  provided  not  as  a  partial  sub- 
stitute for  wages  but  as  an  addition  to  wages  and,  second,  that  under  the 
gFoup  plan  insurance  is  available  for  some  employees  who  could  not  pass 
the  medical  examination  required  of  applicants  for  individuaal  insurance. 

The  first  argument  is  supported  by  the  statement  that  employers 
who  have  adopted  the  group  life  plan  have  not  reduced  wages  when  they 
put  the  plan  into  operation.  The  second  argument  requires  no  proof,  but 
the  argument  is  re-inforced  by  estimates  of  the  percentage  of  em- 
ployees in  the  average  establishment  who  would  be  unable  to  pass  the 
medical  examination  for  individual  insurance.  A  representative  of  an 
insurance  .company  Avhich  writes  group  life  insurance  asserts  that  "it  is 
a  well  known  fact  that  some  15  per  cent  of  individuals  applying  for 
personal  insurance  cannot  be  accepted"  and  that  "an  average  of  10  per 
cent  of  the  employees  of  any  office  or  plant  would  be  rejected."*^ 

Few  arguments  urged  against  group  life  insurance  by  employers 
have  come  to  the  attention  of  the  Commission — employers  who  are 
opposed  to  the  plan  or  doubtful  of  its  efficacy  commonly  content  them- 
selves with  an  assertion  that  the  plan  will  have  little  or  no  effect  in  en- 
listing the  good-will  of  employees  and  reducing  the  labor  turn-over  or 
that  the  effect  secured  will  not  be  worth  the  cost. 

A  number  of  arguments  against  group  life  insurance  have  been 
made  from  the  point  of  view  of  the  employee.  The  most  important  of 
them  may  be  summarized  as  follows : 

1.  It  "ties  the  workman  to  his  job." 

3.  It  is  designed  and  used  to  prevent  the  organization  and  the 
success  of  trade  unions  among  employees. 

3.  The  operation  of-  the  plan  will  make  it  difficult  for  the  poorer 
"risks"  among  working  people  to  find  and  retain  employment. 

4.  Employees  insured  under  the  plan  are  likely  to  drop  other  in- 
surance. 

5.  The  plan  is  paternalistic  and  autocratic. 

^^  Lawrence  C.  Wood,  paper  cited  above,  p.  8. 


516 


6.  The  future  of  the  plan,  because  its  use  is  entirely  voluntary  with 
employers,  is  uncertain. 

The  first  argument,  the  group  life  insurance  "ties  the  workman  to 
his  job,"  is  based  upon  the  claims  made  for  the  plan  by  the  insurance 
companies  and  its  advocates  among  employers  as  described  in  preceding 
pages  of  this  discussion.  The  truth  of  this  argument,  in  so  far  as  group 
life  insurance  succeeds  in  accomplishing  its  purposes,  cannot  be  denied. 
The  question  to  be  considered  is  whether  it  is  a  good  or  a  bad  thing  for 
employees  to  be  "tied  to  their  jobs"  by  group  insurance.  Representatives 
of  employees  who  object  to  group  insurance  contend  that  it  is  a  bad 
thing.  They  say,  in  effect,  that  it  permits  employers  to  maintain  wage 
standards  and  other  conditions  of  employment  which  are  unfavorable  to 
the  interests  of  employees  and  which  they  could  not  maintain  if  em- 
ployees felt  free  to  change  employers  at  any  time.  Group  life  insur- 
ance, according  to  this  view,  is  purchased  by  the  employee  at  the  cost  of 
low  wages,  long  hours,  unsanitary  working  conditions,  and  the  like. 

The  second  argument,  that  group  life  insurance  is  used  to  prevent 
the  organization  and  success  of  trade  unions,  has  much  the  same  basis 
in  the  theory  as  the  first  argument. 

The  fact  that  the  premium  rates  which  an  employer  will  be  called 
upon  to  pay  for  group  life  insurance  will  vary  ultimately  with  the  mor- 
tality experience  of  the  group  is  the  basis  for  the  third  argument.  In 
detail  the  argument  runs  to  the  effect  that  the  employer  will  be  tempted 
to  discharge  the  poorer  "risks"  among  his  employees  whenever  a  con- 
venient pretext  offers  itself  and  to  refuse  employment  to  all  persons  who 
appear  to  be  poor  "risks."  The  discrimination  against  working  people 
in  the  higher  age  groups  will  be  especially  severe. ^^ 

The  argument  that  employees  insured  under  the  group  plan  will 
be  tempted  to  drop  other  insurance  which  they  may  be  carrying  needs  no 
explanation. 

The  argument  that  group  life  insurance  as  now  administered 
through  the  employer  is  paternalistic  and  autocratic  is  so  obviously  true 
as  to  require  neither  explanation  nor  proof.  In  no  case  which  has  come 
to  the  attention  of  the  Commission  have  the  terms  under  which  group 
life  insurance  is  offered  to  the  employees  by  the  employer  been  the  sub- 
ject of  genuine  collective  bargaining.  But  this  statement  does  not  dis- 
pose of  the  matter.  The  real  question  is  whether  paternalistic  and  auto- 
cratic control  of  the  wage-earner's  insurance  by  the  emplover  and  the 
insurance  company  is  desirable  or  undesirable. 

The  argument  that  the  future  of  group  life  insurance  is  uncertain 
is  based  largely  upon  the  fact  that  the  adoption  of  the  plan  in  the  first 
place  and  its  continuance  after  its  adoption  are  entirely  voluntary  with 
the  employer.  The  following  statement  taken  from  the  benefit  cer- 
tificate issued  to  its  employees  by  a  company  which  has  adopted  ffroup 
life  insurance  illustrates  this  fact: 

"This  action  is  voluntary  on  the  part  of  the  Company.  It  constitutes 
no  contract  with  any  employee,  and  confers  no  legal  rights  on  either. 
*     *     *•     "The  Company  pays  all  costs,  and  the  title  to  all  Dolicies  vests 


It. 


«  Compare  the  table  on  page  23  above  and  the  discussion  on  page  24  following 


517 

absolutely  in  the  Conlpan3^  The  Company  reserves  the  right  to  alter 
or  abrogate  the  plan  if  future  legislation  or  other  circumstances  render 
this  advisable." 

It  is  also  argued  that  the  future  of  group  life  insurance  is  uncertain 
because  this  form  of  insurance  "is  not  based  upon  the  scientific  principle 
of  individual  physical  examination." 

The  first  four  arguments  against  group  life  insurance  which  have 
been  stated  above  involve  questions  of  fact  which  the  Commission  is 
unable  to  answer  from  the  data  available  to  it.  In  advance  of  the  ver- 
dict of  the  facts,  it  is  fair,  however,  to  predict  that  the  truth  of  the  argu- 
ments mentioned  will  eventually  have  to  be  disproved  if  group  life 
insurance  as  now  written  is  to  receive  the  approval  of  organized  labor 
in  Illinois. 

The  force  of  the  argument  that  group  life  insurance  is  paternalistic 
and  autocratic  depends  in  the  main  upon  the  truth  of  the  first  four  argu- 
ments. Judgment  must  therefore  be  reserved  upon  the  real  issues  raised 
by  this  argument. 

The  argument  that  the  future  of  group  insurance  is  uncertain 
is  obviously  true.  This  is  not,  however,  because  of  the  elimination  of 
the  medical  examination  in  the  selection  of  group  risks  for  there  is  no 
reason  to  doubt  the  actuarial  soundness  of  the  group  plan.  The  future 
of  group  life  insurance,  as  a  voluntary  plan,  is  uncertain  because  this 
form  of  insurance  is  still  an  experiment  with  employers.  It  has  been 
adopted  by  only  a  small  minority  of  employers  and  these  employers, 
with  few  exceptions,  have  turned  to  it  in  a  period  of  rising  wages  and 
*'labor  unrest."  To  a  considerable  extent  the  employers  who  have 
adopted  the  plan  have  done  so  for  the  sake  of  the  advantages  they  think 
that  it  affords  them  in  competing  for  men  in  a  labor  market  where  the 
competition  for  men  has  been  unusually  keen.  Before  the  State  can 
place  much  reliance  upon  voluntary  group  life  insurance  as  a  means  of 
meeting  the  need  of  the  wage-earner  for  insurance  some  evidence  must 
be  forthcoming  that  employers  who  adopt  the  plan  will  not  abandon  it 
as  soon  as  the  conditions  which  have  prevailed  in  the  labor  market  of 
the  last  few  years  have  given  way  to  conditions  more  nearly  normal. 
Evidence  must  also  be  forthcoming  that  the  plan  will  be  adopted  by  many 
more  employers  than  have  yet  adopted  it  in  Illinois. 

In  conclusion  it  should  be  pointed  out  that  voluntary  group  life 
insurance  at  best  will  not  meet  the  needs  of  all  wage-earners  now  un- 
provided with  life  insurance  for  the  successful  operation  of  the  plan  is 
practically  limited  to  groups  numbering  50  or  more  employees  and  there 
are  many  employees  in  Illinois  who  are  not  employed  in  such  groups. 

III.  Group  Health  and  Accident  Insurance. 

(1)  History. — The  terms  "Group  Health  Insurance"  and  "Group 
Accident  Insurance"  seem  to  have  been  applied  in  imitation  of  the  term 
"Group  Life  Insurance,"  and  to  have  come  into  use  only  in  the  past  few 
years.  The  group  plan,  however,  has  been  used  in  accident  insurance 
for  a  much  longer  time  than  the  name  and  the  plan  was  attempted  in 
health  insurance  before  the  name  was  attached  to  it. 


518 

So  far  as  the  Commission  has  been  able  to  ascertain,  the  first  group 
policies  which  appeared  in  the  health  and  accident  insurance  field  were 
the  so-called  'Workmen's  collective  insurance'^  policies.^^  Workmen's 
collective  insurance  has  been  defined  as  "the  accident  insurance  of  a 
number  of  workmen  collectively  under  one  policy,  as  contrasted  with 
the  individual  policy  for  each  man  *  *  *  the  personal  accident 
insurance  of  workmen  by  wholesale  instead  of  by  retail."'^*  It  will  be 
noted  that  the  definition  confines  the  term  to  accident  insurance.  One 
insurance  company  which  attempted  to  write  health  insurance  on  a 
collective  policy  before  the  term  "group  health  insurance"  came  into 
use  failed  to  find  any  demand  for  the  policy  and  finally  withdrew  it.*^ 
The  Aetna  Life  Insurance  Company,  however,  states  that  it  "had  written 
blanket  accident  and  health  contracts  as  early  as  1898. 

Workmen's  collective  insurance  is  said  to  have  originated,  under  a 
different  name,  in  England  in  1882.*®  Information  as  to.  the  first  ap- 
pearance of  this  form  of  insurance  in  the  United  States  is  not  available. 
Workmen's  collective  insurance  for  reasons  which  will  be  stated  pres- 
ently, has  never  been  of  much  importance  either  in  Illinois  or  the  United 
States  as  a  whole.  It  is  discussed  here  because  of  the  light  its  history 
may  throw  upon  the  possibilities  of  group  health  and  accident  insurance. 

Workmen's  collective  insurance  has  been  written  on  two  types  of 
policies:  first,  and  most  important  from  the  standpoint  of  amount 
written,  policies  covering  occupational  accidents  only,  and,  second, 
policies  covering  both  occupational  and  non-occupational  accidents. 
Typical  benefits  provided  under  workmen's  collective  insurance  run  as 
follows : 

"(a)'  In  the  event  of  death  within  ninety  days  from  the  date  of  the 
accident,  a  sum  equal  to,  but  not  exceeding  one  year's  wages  limited 
to  $1,500. 

"(b)  For  the  loss  of  two  limbs  or  two  eyes,  a  sum  equal  to  the 
amount  payable  under  the  policy  at  death. 

"(c)  For  the  loss  of  one  limb,  a  sum  equal  to  one-third  the  amount 
payable  under  the  policy  at  death. 

"(d)  For  the  loss  of  one  eye,  a  sum  equal  to  one-third  the  amount 
payable  under  the  policy  at  death. 

"(e)  In  the  event  of  temporary  total  disability,  .a  sum  equal  to  but 
not  exceeding  one-half  the  weekly  wages  for  a  period  not  exceeding 
twenty-six  weeks,  such  sum  not  to  exceed  $750  in  respect  to  any  one 
person  injured  during  the  policy  year. 

"The  usual  rates  are  for  the  foregoing  benefits  only,  covering  acci- 
dents of  occupation  during  working  hours  only. 

"If  the  benefits  under  clauses  (a),  (b),  and  (c)  be  reduced  one-half, 
the  rate  is  15  per  cent  less.     *     *     *. 

"If  the  policy  is)  written  to  cover  the  whole  twenty-four  hours,  i  e., 
the  exposure  of  the  workman  to  accidents  while  away  from  work  as  wel( 

^  "  ?u^  ^^^\  ^®^®  Pr.?^r^"t®^  ^^  workmen's  coHective  insurance  are  taken  chiefly 
TT^ir^H  <lf/to2^MLo^  Workmen's  Collective  Insurance"  by  Charles  H.  Franklin. 
rr««  T^..^innn^%nr^^o«^"'^.  Attorney  of  the  Frankfort  Marine,  Accident  and  Plate 
Glass  Insurance  Company.  In  Dunham's  Business  of  Insurance,  Vol.  II,  pp.  144-150. 

**  iDia.,   p.   144. 

"Ibid.,   p.    148. 

*«Ibid,  144. 


M9 

as  the  hazard  of  his  occupation  the  additional  charge  *  *  *  is  l5 
per  cent. 

"If  full  medical  attendance  is  desired,  30  per  cent  of  the  full  rates 
is  added,  whether  the  death  benefit  is  one  yearns  or  one-half  year's  wages, 
save  only  that  if  the  full  twenty-four  hours  are  covered,  371/^  per  cent 
is  added/'"*' 

The  premiums  for  workmen's  collective  insurance  are  based  on  the 
payroll  and  they  have  varied  in  general  from  1  to  5  per  cent.*^  As  in 
group  life  ins-urance  the  premium  may  be  paid  entirely  by  the  employer 
or  it  may  be  divided  between  the  employer  and  the  employees.  In  some 
cases  the  employees  have  paid  the  entire  premium,  the  employer  collect- 
the  amount  or  deducting  it  from  wages  and  making  payment  to  the  in- 
surance company.  "On  any  workmen's  collective  policy  a  commission 
of  5  per  cent  may  be  paid  to  the  employer  for  collecting  the  premium."*^ 

The  reasons  Avhich  have  been  assigned  for  the  failure  of  workmen's 
collective  insurance  to  assume  greater  importance  may  be  summarized 
as  follows: 

(1)  The  insurance  companies  did  not  "push"  the  business  except 
for  a  few  years  prior  to  the  appearance  of  Workmen's  Compensation 
laws. 

(2)  Employers  and  employees  were  unwilling  to  pay  the  premium 
rates  which  seemed  high  "in  comparison  with  the  premiums  charged  by 
friendly  societies  and  industrial  insurance,  assessment  and  stock  com- 
panies."^*^ 

(3)  Trade  unions  have  opposed  the  use  of  this  form  of  insurance 
because  it  tended  to  detach  employees  from  the  unions  and  to  interfere 
with  the  maintenance  of  trade  union  insurance  funds  and  because  only 
half  wages  were  paid  under  it  for  time  lost  on  account  of  disability. 

(4)  The  enactment  of  Workmen's  Compensation  laws  has,  in  large 
part,  destroyed  the  small  demand  that  had  been  developed  for  this-  form 
of  insurance. 

The  relative  unimportance  of  workmen's  collective  insurance  in  the 
United  States  is  shown  by  the  fact  that  the  total  premium  income  re- 
corded for  this  kind  of  business  in  the  United  States  by  the  Insurance 
Year-Book  for  1916  for  the  five-year  period,  1911  to  1915  inclusive,  was 
only  $3,454,752  or  a  yearly  average  of  $691,000.  The  totals  for  the 
premiums  on  accindent  and  health  insurance  for  the  same  period  were, 
respectively,  $164,154,125  and  $35,461,204  and  the  yearly  averages, 
respectively,  about  $33,000,000  and  $7,100,000.^1 

Workmen's  collective  insurance  has  almost  entirely  disappeared 
from  the  insurance  field  in  Illinois.  The  report  of  the  Insurance  Super- 
intendent of  Illinois  for  1917  shows  that  5  insurance  companies  collected 
premiums  totalling  $529.09  for  workmen's  collective  insurance  in  Illi- 
nois during  the  year  1915  and  paid  losses  totalling  $391.56.  In  1916 
the  three  companies  which  reported  data  for  workmen's  collective  insur- 

"  Franklin,  cited  above,  pp.  144-145. 
^8  Ibid.,  pp.  145-146. 
^"Franklin,  cited  above,  p.  145. 
••«Ibid.,  p.  147. 

•'^Insurance  Year-Book  for  1916,  Life,  Casuo.lty  and  Miscellaneous,  pp.  A164  and 
A165. 


520 

auce  appear  as  a  group,  to  have  returned  to  policyholders  on  cancelled 
policies  $197.35  more  than  they  collected  as  premiums  and  to  have  paid 
losses  amounting  to  $4,121.^- 

In  the  past  few  years  some  of  the  "blanket"  health  and  accident 
policies  which  have  been  offered  employers  for  the  insurance  of  their 
employees  have  been  called  "group"  policies  instead  of  workmen's  col- 
lective policies.  The  term  seems  to  have  been  adopted,  as  has  already 
been  suggested,  in  imitation  of  the  name  "group  life  insurance."  The 
comparative  failure  of  workmen's  collective  insurance  and  the  danger 
of  confusing  its  name  witH  workmen's  compensation  insurance  may 
have  been  reasons  for  the  adoption  of  the  newer  name. 

Very  little  group  health  and  accident  insurance,  as  such,  has  been 
written  either  in  Illinois  or  in  the  United  States  as  a  whole.  Data 
showing  the  exact  amount  outstanding  are  unfortunately  not  available. 

A  prominent  official  in  a  company  writing  insurance  of  this  kind 
and  a  student  of  the  subject  advises  the  Commission  under  date  of 
September  13,  1918,  that  "this  branch  of  the  business  is  still  in  its 
infancy"  and  that  he  doesn't  "imagine  that  there  is  over  $500,000  in 
premiums  on  this  business  in  force  to-day."  He  adds  that  "very  few 
companies  are  now  writing  this  kind  of  business  and  (that)  there  are 
very  few  printed  forms  of  policies  because  of  the  fact  that  the  demands 
of  each  employer  are  peculiar  to  himself  and  this  necessitates  a  special 
form  of  policy  for  practically  every  case." 

(2)  Group  health  and  accident  insurance  in  Illinois. — Returns  of 
the  questionnaires  sent  to  insurance  companies  by  the  Commission  show 
that  three  of  the  companies  which  write  group  life  insurance  in  Illinois 
also  offer  group  health  and  accident  insurance.  However,  only  one  of 
these  companies  reported  group  health  or  accident  policies  as  outstanding 
against  it  in  Illinois.  Information  available  to  the  Commission  indi- 
cates that  several  casualty  companies  which  do  business  in  Illinois  also 
write  group  health  and  accident  insurance. 

As  has  been  stated  above,  very  little  group  health  and  accident  in- 
surance has  been  written  in  Illinois.  Some  of  the  few  insurance  com- 
panies which  offer  health  and  accident  insurance  on  group  policies  have 
as  yet  to  write  their  first  policies  of  this  type  in  this  State. 

(3)  Group  health  and  accident  insurance  contracts. — The  lack  of 
standardization  in  the  policies  used  in  group  health  and  accident  insur- 
ance has  already  been  mentioned.  Because  of  the  variety  of  contracts 
used  by  different  companies  and  by  the  same  company  for  different 
groups  it  is  impossible  to  select  a  typical  policy  for  a  summary  descrip- 
tion. One  of  the  companies  named  above  writes  group  accident  or  health 
insurance  for  groups  of  not  less  than  50  employees.  This  company 
describes  its  group  policies  as  follows  in  an  adverising  pamphlet  which 
it  issues: 

"Accident  insurance.— "Th^  Company  is  prepared  to  sell  any  kind  of 
accident  insurance  benefits  desired  by  employers.  Our  standard  form 
of  group  policy,  however,  provides  accident  indemnities  equivalent  to 
one-half  the  average  wages  of  the,  employee— limit  one  year— while 
totally  disabled  by  accidental  injury  and  one  full  years'  wages  for  acci- 

'^  Insurance  Report,  Illinois,  1917,  Part  III,  p.  8. 


521 

dental  death.  It  covers  both  occupational  and  non-occupational  injuries 
and  the  insurance  is  effective  twenty-four  hours  a  day.  Larger  or 
smaller  indemnities  are  sold  at  proportionate  rates. 

''Health  insurance. — Our  Company  is  prepared  to  sell  any  kind  of 
health  insurance  benefits  desired  by  employers.  Our  standard  form  of 
group  policy,  however,  provides  illness  indemnities  equivalent  to  one- 
half  the  average  wages  of  the  employee — limit  one  year — while  totally 
disabled  by  illness.  As  most  employees  are  able  to  stand  a  few  days' 
illness  without  financial  embarrassment,  most  employers  do  not  desire 
the  first  seven  days  of  illness  to  be  covered — thereby  effecting  a  large 
reduction  in  premium  charge.  Larger  or  smaller  indemnities  are  sold 
at  proportionate  rates. 

^^ Accident  and  health  insurance. — We  are  also  prepared  to  sell  group 
accident  and  health  insurance — under  a  single  policy."  • 

Another  company  in  its  standard  form,  which  is  a  combined  acci- 
dent and  health  policy,  limits  the  payment  of  indemnity  for  disability 
from  either  accident  or  illness  to  26  weeks  and  pays  no  indemnity  for 
the  first  week.  The  amount  of  the  weekly  indemnity  in  this  case^  so 
far  as  the  policy  form  shows,  is  not  determined  by  the  wages  of  the 
employee  but  is  such  sum  as  may  be  agreed  upon  with  the  employer.    . 

A  third  company  issues  a  group  health  policy  in  which  it  promises 
to  pay  sickness  indemnity,  at  a  rate  to  be  agreed  upon  with  the  em- 
ployer, "for  each  working  day  (Sundays  and  legal  holidays  excepted), 
beginning  with  the  first  treatment  of  physician  and  not  exceeding  six 
consecutive  months"  of  total  disability  for  which  the  employee  "is  treated 
by  a  legally  qualified  physician  at' least  once  in  each  seven  days." 

(4)  The  cost  of  group  health  and  accident  insurance. — Group 
health  and  accident  insurance,  like  group  life  insurance,  is  issurance 
at  wholesale.  The  omission  of  medical  examination  under  the  group 
plan  is  not  a  factor  making  for  lower  rates  in  health  and  accident  in- 
surance for  medical  examination  is  usually  omitted  on  the  individual 
policies  in  these  forms  of  insurance,  but  the  other  economies  mentioned 
in  the  group  life  insurance  plan  are  realized  to  a  greater  or  less  extent 
in  the  writing  of  health  and  accident  insurance  on  the  group  plan,  j^ 

"By  selling  the  insurance  in  wholesale  lots,  so  to  speak,  the  insur- 
ance company  effects  a  considerable  reduction  in  overhead  expenses  and 
agents'  commissions,  and  as  a  result,  the  actual  cost  of  the  insurance  is 
materiallv  reduced. "^^ 

"By  covering  the  employees  in  groups  the  premium  can  be  quite 
materially  reduced  and  it  is  customary  to  pay  only  a  very  small  agent's 
commision  for  this  class  of  business — usually  71^  or  10  per  cent."^* 

Because  of  the  variety  which  exists  among  the  group  health  and 
accident  insurance  contracts  which  have  been  written  or  put  on  the 
market  it  is  impossible  to  make  any  very  definite  statement  of  the  cost 
of  group  health  and  accident  insurance.  Attention  may,  however,  be 
called  to  the  statement  on  a  previous  page  that  the  premiums  for  work- 
men's collective  insurance    (covering  accidents  only)    "have  varied   in 

"  Pamphlet    issued    by    the    Massachusetts    Bonding    and    Insurance    Company 
(Form  1055 — no  title),  p.  9. 

•'"'^Letter  dated  September  13,  1918,  from  insurance  oflficial  referred  to  above. 


522 

general  from  1  to  5  per  cent"  and  to  estimates  made  by  two  of  the  in- 
surance companies  which  have  been  mentioned  above.  One  of  these  com- 
panies estimates  the  "total  cost"  of  group  health  and  accident  insurance 
written  on  the  basis  of  wages  as  "ranging  from  only  1  per  cent  to  possi- 
bly 1%  per  cent  of  the  payroll." 

(5)  Advantages  and  disadvantages  of  group  health  and  accident 
insurance. — The  advantages  claimed  for  group  health  and  accident  in- 
surance are  very  similar  to  those  claimed  for  group  life  insurance  and 
need  not  be  stated  in  detail  here. 

The  objections  which  have  been  urged  or  which  may  be  urged 
against  group  health  and  accident  insurance  as  a  means  of  meeting  the 
wage-earner^s  need  for  insurance  are  much  the  same  as  those  which 
have  been  urged  against  group  life  insurance.  In  general  it  may  be  said 
that  if  the  group  plan  proves  largely  successful  in  providing  the  wage- 
earner  with  life  insurance  it  is  likely  to  be  important  in  providing  the 
wage-earner  with  health  and  non-industrial  accident  insurance  unless 
the  double  insurance  burden  proves  to  be  more  than  employers  will 
voluntarily  carry.  In  conclusion,  the  fact  that  group  insurance  is  still 
an  experiment  with  the  results  uncertain  and  that  at  best  it  will  not 
afford  a  comprehensive  solution  for  the  problem  of  insurance  for  wage- 
earners  should  again  be  emphasized. 


523 


SPECIAL    REPORT   X.     FOREIGN    BENEFIT   SOCIETIES    IN 

CHICAGO. 

(By  Jakub  Hordk.) 


[Note  by  the  Secretary. — In  order  that  definite  information  might  be  obtained 
relating  to  the  insurance  provided  by  foreign  societies  the  Commission  employed 
Mr.  Jakub  Horak  to  make  as  extensive  an  investigation  of  those  in  Chicago  as  the 
time  available  would  permit.  Inquiry  would  indicate  that  the  societies  in  Chicago 
do  not  differ  essentially  from  those  in  other  industrial  centers  in  the  State  in  which 
the  foreign  born  are  found  in  considerable  numbers.  Mr.  Horak  is  a  Fellow  in 
Sociology  at  the  University  of  Chicago,  and  had  a  valuable  experience  gained  in  a 
study  of  the  Americanization  of  the  Immigrant.  The  task  to  which  he  was  assigned 
was  a  most  difficult  one.  His  results  are  submitted  as  an  introductory  study  of 
the  subject.] 

Introduction. 

According  to  the  Federal  Census/  Chicago's  foreign  born  in  1910 
numbered  781,217  or  37.4  per  cent  of  the  total  population  of  2,185,283. 
The  native  offspring  of  foreign  born  parentage  added  912,701  to  this 
number.  Thus  the  combined  figure  for  the  foreign  born  white  and  their' 
offspring  of  the  first  generation  was  1,693,918  or  79.2  per  cent  of  the 
entire  population.  In  all  probability  this  factor  constitutes  about  the 
same  percentage  of  the  total  population  to-day.  Of  this  group  in  the 
population,  perhaps  about  73.9  per  cent  are  of  races  from  the  continent 
of  Europe  whose  mother  tongue  is  other  than  English.  Prominent 
among  them  are  Germans,  Scandinavians,  Italians,  Czechs,  Jews  and 
others  who  have  a  strong  tendency  to  organize  for  various  purposes — 
social,  athletic,  educational,  religious  and  "beneficiary."  An  attempt 
has  been  made  to  study  in  some  detail  their  societies  in  so  far  as  they 
provide  for  meeting  the  problems  of  sickness,  accident  and  death. 

How  many  foreign  societies  there  are  in  Chicago  without  affiliation 
with  national  fraternal  orders  or  other  national  organizations  is  hard 
to  estimate.  An  extensive  search  for  lists  of  these  among  the  different 
foreign  groups  has  uncovered  few  and  most  of  the  lists  found  have  been 
of  limited  assistance  because  of  a  rapidly  changing  situation.  N'ew 
societies  are  all  the  while  being  formed ;  many  of  the  old  ones  disappear 
because  of  lack  of  success  in  their  endeavors  or  because  their  members 
affiliate  with  other  organizations  or  move  away  or  because  these  societies 
tend  strongly  to  become  locals  of  national  fraternal  orders.  Under  the 
circumstances  it  has  been  necessary  to  secure  the  names  of  independent 
societies  from  other  sources — priests  and  clergymen,  political  leaders, 
newspaper  men,  social  settlements,  saloon-keepers,  undertakers  and  the 
officers  of  societies  themselves.  As  a  result  of  inquiries  at  all  available 
sources  the  number  of  independent  foreign  societies  in  Chicago,  ex- 
clusive of  athletic  clubs,  building  and  loan  associations,  entertainment 
clubs  and  singing  societies,  is  estimated  at  about  600.  A  list  giving 
names  and  addresses  of  560  of  these  has  been  made.     Some  of  these 


devote  their  attentioiH^ducational,  political  or  social  affairs  exclusively. 
Others,  and  especially  many  of  those  among  the  Jews,  are  primarily 
charitable  organizations.  Excluding  those  of  all  the  types  mentioned, 
it  is  estimated  that  there  are  something  more  than  300  independent 
foreign  societies  in  Chicago  which  make  more  or  less  extensive  and 
definite  provision  for  meeting  the  problems  connected  with  sickness, 
accident  and  death.  The  investigation  has  been  limited  to  these.  De- 
tailed information  with  reference  to  the  provision  made  and  its  ad- 
ministration has  been  secured  from  161  of  the  313  found.  In  so  far  as 
possible,  those  studied  have  been  selected  so  as  to  be  typical  with  refer- 
ence to  race,  size,  and  nature  of  the  benefits  provided.  Table  I,  follow- 
ing, shows  the  number  of  known  benefit  societies  among  the  several 
races,  the  number  of  the  same  studied,  their  membership  and  the  kinds 
of  benefits  provided  by  them. 

TABLE  I — INDEPENDENT  FOREIGN  BENEFIT  SOCIETIES'  IN  CHICAGO. 


Es- 
timated 
number. 

Number 
studied. 

Number 

of 

members 

of  those 

studied. 

Number  of  those  studied  providing  each 
specified  kind  of  benefit. 

Nationality. 

Death. 

Fun- 
eral. 

Sick- 
ness 
and 
acci- 
dent. 

Hos- 
pital. 

Medi- 
cal. 

Croatian 

5 

1 

90 

44 

14 

80 

14 

30 

2 

6 

3 

1 

11 
1 
3 
2 
6 

3 
1 
57 
18 
9 
33 
4 
8 
2 
6 
2 
1 
7 
1 
2 
1 
6 

170 

140 

2,872 

2,302 

1,565 

3,569 

801 

1,588 

206 

1,596 

2,810 

100 

2,384 

80 

100 

110 

631 

3 

1 

40 

17 

8 

25 

3 

8 

2 

5 

i' 

6 
1 
2 
1 
2 

1 

1 

39 

12 

3 

16 

2 

5 

2 

3 

1 

6' 

1 

1 
1 
3 

3 
1 

14 
14 
6 
28 
2 
7 
2 
4 
1 
1 
6 
1 
2 
1 
1 

1 

2 

Croatian-Czech 

Czecho-slovak 

German 

8" 

1 

Greek 

4 

Italian 

11 

Jewish 

Lithuanian 

Ivithuanian-polish 

Magyar 

Polish 

Russian 

Scandinavian 

1 

Serbian 

Slovak 

Slovenian 

Miscellaneous 

Total 

313 

161 

21,024 

125 

97 

94 

9 

19 

Before  commenting  on  the  main  facts  set  out  in  this  table,  it  will 
be  of  interest  to  note  that  these  societies  are  not  only  independent  of 
national  foreign  and  fraternal  orders,  but,  with  few  exceptions,  of  all 
other  institutions  as  well.  Contrary  to  the  general  impression,  relatively 
few  of  them  are  connected  with  churches  or  have  a  definitely  religious 
aspect.  The  chief  exceptions  are  among  the  Italians  and  some  of  the 
Gcnnan  societies.  It  should  be  said,  too,  that  the  Catholic  churches 
without  regard  to  race  have  benefit  organizations  within  them,  but  these 
have  found  no  particular  place  in  this  study.  Yet*  it  is  not  to  be 
assumed  that  the  societies  studied  are  merely  insurance  carriers  or 
organizations  for  providing  medical  care.  The  fact  is  that  most  of  them 
are  much  more  than  mere  benefit  societies.     They  may  and  usually  do 


525 


combine  with  these  activities  general  social,  or  political,  or  educational 
interests. 

Turning  to  Table  I,  it  will  be  noted  that  while  the  proportion  of 
the  societies  studied  for  the  several  races  varied  materially,  a  sufficient 
number  were  studied  in  every  case  to  give  the  needed  representation.  It 
will  be  noted,  also,  that  the  number  studied  had  a  combined  membership 
of  21,024,  an  average  of  about  130  each.  If  those  from  which  detailed 
information  was  obtained  are  typical  in  respect  to  size,  the  total  be- 
longing to  the  313  societies  listed  would  be  approximately  40,690.  Of 
course  these  societies  varied  considerably  in  size,  a  fact  brought  out  in 
Table  II  for  the  161  from  which  detailed  information  was  obtained. 

TABLE   II— INDEPENDENT   FOREIGN    SOCIETIES    STUDIED   BY   RACE   AND 

NUMBER  OF  MEMBERS. 


Total 
studied. 

Number  with  each  number  of  members  specified. 

Nationality. 

Less 
than  50. 

50 

but  less 

than 

100. 

100 

but  less 

than 

150. 

150 

but  less 

than 

200. 

200 

but  less 

than 

300. 

300 

but  less 

than 

400. 

400 

but  less 

than 

500. 

500  or 
over. 

Croatian 

3 
1 

57 
18 
9 
33 
4 
8 
2 
6 
2 
1 
7 
1 
2 
1 
6 

1 

2 

Croatian-czech 

1 
9 
1 

1 
7 

3' 

1 
1 

i 

Czecho-slovak 

16 
2 

io' 

21 
8 
5 

7 

1 
2 

1 

1 
4 

1 
5 
2 

3 
3 

4" 

2' 

4 

2 

1 

German 

Greek 

1 

1 

Italian 

Jewish 

1 

. 

Lithuanian 

1 

Lithuanian-PoUsh 

Magyar 

1 

2 

1 

1 

Polish 

1 

1 

Russian 

1 

Scandinavian 

3 

2 

1 

1 

Serbian 

i' 

1 
1 

Slovak 

Slovenian 

1 

Miscellaneous 

3 

2 

1 

........ 

Total 

161 

34 

51 

26 

14 

17 

9 

5 

5 

Eeverting  to  Table  I,  it  will  be  noted  that  while  a  great  variety  of 
benefits  are  provided,  few  societies  make  provision  for  all  the  benefits 
listed — death,  "funerah"  sickness  and  accident,  and  hospital  and  medical 
care.  Indeed  the  great  majority  provide  only  cash  benefits  of  one  kind 
or  another.  First  in  emphasis  are  death  benefits  provided  by  125  of  the 
161.  Xext  in  order  come  funeral  benefits  in  the  form  of  flowers,  the 
provision  of  carriages  and  the  like,  provided  by  97  or  about  three-fifths 
of  the  entire  number.  Sickness  and  accident  benefits  are  provided  by 
94.     ISrineteen  furnish  medical  care,  9  provide  hospital  treatment. 

The  membership  of  the  societies  providing  each  kind  of  benefit  is 
of  interest.     This  is  shown  in  Table  III. 


526 


TABLE    III— SHOWING   NUMBER   OF    SOCIETIES    AND    MEMBERSHIP    PRO- 
VIDING  BENEFITS    OF    SPECIFIED    KINDS. 


I 


Kind  of  benefits. 


Number 
providing. 


Membership. 


Death  benefits 

Funeral  benefits 

Sickness  and  accident  benefits 

Hospital  treatment 

Medical  treatment 

Total  societies  studied 


18,336 

13,545 

12,070 

1,535 

2,545 


21,024 


Membership  Rides,  Organization  and  Administration. 

Before  presenting  the  details  relating  to  tlie  benefits  provided  by 
these  societies  something  should  be  said  with  reference  to  their  rules 
relating  to  membership,  organization  and  administration. 

Membership  in  these  societies  is  limited  to  persons  of  mature  years. 
Some  admit  males  only,  some  females  only,  while  others  accept  both 
males  and  females  as  members.  In  all  cases  applicants  for  membership 
must  be  nominated  by  one  or  more  members  of  the  society  and  be 
approved  by  a  membership  committee.  The  applicant  must  belong  to  a 
given  race  or  at  least  be  able  to  speak  or  understand  a  given  foreign 
language.  Now  and  then  he  must  belong  to  a  particular  religious  sect. 
In  all  cases  the  rules  state  that  the  applicant  must  be  of  good  moral 
character,  and  frequently  where  sickness  benefits  are  provided,  he  must 
pass  a  medical  examination  as  a  condition  for  admission. 

Naturally  the  organization  of  these  societies  is  comparatively  simple. 
The  usual  list  of  officers  includes  a  president,  vice  president,  recording 
secretary,financial  secretary,  treasurer,  and  marshal.  These  are  usually 
elected  for  a  period  of  one  year  and  in  some  cases  they  become  ineligible 
for  office  for  a  certain  time  after  thev  have  served  for  two  years.  Inas- 
much  as  most  of  these  societies  are  very  small,  little  time  is  as  a  rule 
required  for  the  performance  of  their  duties.  Generally  only  the 
financial  secretary  and  the  treasurer  receive  any  remuneration  and  the 
sums  paid  are  modest.  In  addition  to  the  general  officers  mentioned 
above,  each  society  has  its  board  of  trustees  and  a  number  of  committees. 
There  is  always  a  committee  on  admission  of  new  members.  The 
societies  paying  sick  benefits  have  a  committee  or  committees  charged 
with  the  duty  of  visiting  sick  members  at  least  once  a  week  and  of  report- 
ing to  the  society.  Where  provision  is  made  for  funeral  benefits,  a 
"funeral  committee"  is  found. 

Regular  meetings  of  the  societies  are  held  weekly,  bi-weekly, 
monthly  or  at  longer  intervals.  The  election  of  officers  and  the  selection 
of  standing  committees  ordinarly  takes  place  at  a  meeting  held  in 
December. 


Death  Benefits. 

As  stated  above.  125  of  the  161  societies  investigated  pay  a  death 
benefit  in  the  case  of  the  death  of  a  member  in  good  standing.  The 
total  membership  of  the  125  is  1^,336,  an  average  of  approximately  146. 
While  the  average  membership  of  these  societies  is  somewhat  larger  than 


527 

that  of  the  total  number  studied,  it  is  important  to  note  that  the  great 
majority  of  the  societies  are  small  from  the  point  of  view  of  the  number 
required  to  carry  a  liability  of  this  kind  in  a  satisfactory  manner. 

Almost  two-thirds  of  the  societies  paying  death  benefits  to  the  de- 
pendents of  deceased  members  pay  a  stipulated  amount  out  of  the  general 
fund  or  out  of  the  funds  derived  from  assessments.  The  smaller  num- 
ber, on  the  other  hand,  pay  over  to  the  dependents  the  sum  collected 
from  an  assessment  upon  the  membership  levied  on  occasion  of  or  prior 
to  the  death. 

The  smallest  death  benefit  paid  bv  anv  of  the  societies  from  which 
information  was  obtained  was  $15,  the  largest  $250.  One  pays  $15' 
four,  $25  but  less  than  $50;  twenty-six,  $50  but  less  than  $75;  three, 
$75  but  less  than  $100;  twenty-three,  $100  but  less  than  $150;  eleven, 
$150  but  less  than  $200;  six.  $200  but  less  than  $250;  three,  $250. 

The  amount  of  the  benefit  paid  by  the  remaining  48  societies  de- 
pends upon  two  factors,  first  the  number  of  members  upon  whom  the 
assessments  are  levied,  and  secondly,  the  amount  of  the  assessment. 
Six  societies  levied  an  assessment  of  50  cents  per  member,  38  an  assess- 
ment of  a  dollar,  and  14  an  assessment  of  $2  to  meet  each  death  claim. 

No  further  comment  is  needed  except  to  note  that  the  death  benefit 
paid  is  in  all  cases  a  very  modest  sum  and  is  intended  to  pay  the  funeral 
expenses  and  the  bills  incident  to  the  sickness  which  has  ended  fatally. 

A  few  of  these  societies  pay  a  death  benefit  in  the  event  of  the  death 
of  the  wife  or  child  of  a  member.  The  amount  of  this  benefit  is  as  a 
rule  half  the  sum  paid  on  the  occasion  of  the  death  of  a  member.  If 
special  dues  are  collected  for  the  payment  of  such  benefit,  they  are  half 
the  sum  levied  for  the  payment  of  benefits  for  members. 

Data  were  obtained  from  the  several  societies  .relating  to  their  mor- 
tality experience  and  death  claims  paid  for  the  year  1917.  The  total 
number  of  claims  paid  was  250,  the  amount  $36»308.73. 

Funeral  Benefits. 

In  close  connection  Avith  death  benefits,  a  word  should  be  said  with 
reference  to  "funeral  benefits."  These  relate  to  flowers,  carriages,  and 
the  like  furnished  when  a  member  dies  and  to  the  announcement  made 
through  the  press.  Most  of  the  societies  make  some  provision  of  this 
character.  Just  what  is  done  in  a  given  case  is  ordinarily  decided  in  a 
meeting  called  when  a  member  dies.  A  sum  is  voted  to  defray  the  ex- 
pense involved.  In  some  cases,  however,  a  customary  sum  is  allowed. 
In  either  event'  any  balance  left  after  the  expenses  are  met  is  given  to  the 
dependents. 

Sickness  and  Accident  Benefits. 

Of  the  161  societies  studied,  94  with  a  combined  membership  of 
12,070,  w^ere  found  to  pay  "sickness  benefits."  In  all  cases  accident, 
industrial  or  non-industrial,  is  treated  as  sickness.  Hence,  except  when 
some  special  provision  is  made  for  accident  caseS'  the  rule  applicable  to 
disability  due  to  sickness  is  applicable  to  disability  due  to  accident.  A 
few  instances  have  been  found,  however,  in  Avhich  some  special  provision 
has  been  made  for  accident  but  not  for  sickness  cases.  Some  of  the 
Greek  societies,  for  example,  pay  a  uniform  sum,  say  $100,  as  an  acci- 


528 


n 


(lent  disability  benefit.  In  other  instances  a  part  of  the  death  benefit, 
usually  50  per  cent,  may  be  advanced  to  a  member  who  becomes  totally 
disabled  by  reason  of  accident  sustained. 

The  sick  benefit  systems  are  multi-form  in  their  details.  Though 
a  considerable  degree  of  similarity  may  be  found  among  the  systems 
maintained  by  a  given  race,  there  is  no  approach  to  a  standard  when  the 
societies  are  taken  collectively.  Some  of  the  variations  are  shown  in 
Table  IV  which  is  a  partial  summary  of  the  sick  benefit  systems  studied. 

TABLE  IV— SICKNESS  AND  ACCIDENT  BENEFITS. 


Maximum  number 

Period 

r) 

Number 
with 

of  weeks  first  benefit  period 

of  reduced 

a 

Benefit 

and  amount. 

benefit. 

M 

o 

CO 

waiting 
period. 

paid 
from — 

Maximum 

Weekly 

Weekly 

i 

bo 

a 

period. 

benefit. 

benefit. 

Tl 

_ 

m 

OS 

• 

■tJ   OT 

o 

o 

o 

Nationality. 

o  c 

CO  o 

1 

g 

•3 

t-l 

..-1 

P. 
bC 
C 

2-^ 

CO   fe 

■t.3 

o 

"^  CO 

CO 

CO 

3 

B 

o    . 

St5 

be 

> 

• 

a 

(a 

a 
(-1 

o 

O 

0*j 

o 

CJ 

. 

03 

u 

d  >< 

C(M 

C! 

o 

C«* 

c** 

X 

03 

TS 

_ 

m 

^g 

03 
X3 

>> 

03 

& 

X 
o 

b3  © 

X.  C 

C8 

«T3 

a 

CO 

^ 

.n"^ 

c 

-tJ 

X) 

o 

o 

+J  *j 

■^  « 

■I-' 

o 

+J  « 

-M  <» 

X3 

3 

IM 

^ 

Q'P. 

•M 

2 

T) 

-t^ 

£o 

+; 

S 

•*-* 

3  a 

o 

o 

ti 

c 

o 

o  a 

c  ® 

o 

o 

o  a> 

o  o 

fj 

03 

-tJ 

^ 

Z 

^ 

;^ 

P^ 

W 

^ 

S 

s 

S 

2^ 

S 

s 

^ 

S 

O 

Croatian 

3 
1 

3 
1 

2 
1 

1 

2 
1 

1 

2 

1 

2 
1 

1 

Crnat  i  A  Ti -r^7PoVi 

1 

Czechoslovak     

57 

18 

9 

33 

•  4 

8 

2 

6 

2 

1 

7 

1 

2 

1 

6 

15 
14 
6 
28 
2 
7 
2 
4 
1 
1 
6 
1 
2 
1 
1 

13 
9 
4 

22 
1 

"i 

2 

1 
1 
4 

♦ 

2 

1 
1 

2 
5 

* 

*5 

1 
5 
1 
2 

*14 
9 
2 

♦11 

2 

*6 

1 

4 

'"4 

t 

t9 

3 

1 

2 

.... 

10 
9 
4 
6 
1 

2 

4 

14 
13 
4 
20 
2 
7 
2 

2 

1 

— 

2 

G  erman 

1 
1 
8 

.... 

1 

Greek 

Italian 

22 

12 

10 

2 

Jewish 

Lithuanian    . .  •  . 

7 
2 

7 
2 
4 
1 

7 
2 
4 

Lithuanian-Polish 

- 

Magyar 

4 

1 
1 
4 

4 

Polish 

1 
1 
3 

1 

1 
1 

Russian 

Scandinavian 

2 

3 

♦ 

2 

1 

* 

2 
1 

5 
1 

Serbian 

Slovak 

2 

2 

2 

2 

Slovenian 

1 

1 

Miscellaneous 

1 

1 

1 

1 

Total 

161 

95 

65 

24 

58 

19 

7 

44 

43 

1 

71  i     22 

1 

32 

26 

6 

•  Some  Bocietiees  did  not  report  the  length  of  the  waiting  period  and  are  there- 
fore omitted. 

t  One  Greek  Society  begins  to  pay  the  sick  benefits  from  the  3d  day,  and  one 
from  the  4th  day  of  sickness. 

t  Three  Italian  Societies  are  paying  sick  benefits  from  the  2d  day  of  sickness. 

A  comparison  of  the  number  of  societies  with  sickness  benefit  with 
the  number  of  societies  studied,  by  race,  would  indicate  that  the  tendency 
to  make  such  provision  is  much  stronger  among  some  races  than  among 
others.  Noting  details  in  systems  maintained,  65  were  found  with  a 
wating  period  of  not  to  exceed  a  week  as  against  24  with  one  or  more  than 
a  week.  Some  reckon  benefits  from  the  first  day  of  disability  when  that 
exceeds  the  waiting  period,  others  irom  the  end  of  the  waiting  period. 
The  number  of  weeks  for  which  benefits  may  be  paid  may  be  limited  for 
a  given  illness  and  for  all  illnesses  during  a  year.     Frequently  there  are 


529 

two  benefit  periods,  one  at  the  full  or  normal  sum.  As  shown  by  Table 
IV,  the  maximum  number  of  weeks  at  the  full  rate  or  for  any  benefit  as 
the  case  may  be,  is  not  to  exceed  six  weeks  in  7  cases,  more  than  six  but 
not  to  exceed  thirteen  in  44  cases,  more  than  thirteen  but  not  to  exceed 
twenty-six  in  43  cases,  and  more  than  twenty-six  in  the  remaining  one. 
The  weekly  benefits  paid  for  a  disability  within  these  limits  varies  all  the 
way  from  $2.50  as  a  minimum  to  $15  as  the  maximum.  It  is  not  in 
excess  of  $5  in  71  cases,  is  more  than  $5  but  not  in  excess  of  $10  in  22 
cases.  Only  one  society  pays  a  benefit  of  as  much  as  $15  per  week.  Of 
the  95  societies,  32  pay  benefits  in  reduced  amount  during  a  second 
period,  the  sum  paid  being  half  of  the  normal  except  in  6  cases. 

Three  further  comments  must  be  added  in  connection  with  the 
sickness  benefits  provided  by  these  societies,  (a)  Under  the  rules  of 
some  societies  a  member  whose  sickness  experience  is  very  unfavorable 
or  whose  disability  is  unduly  long  so  that  his  claims  to  benefits  are  ended 
for  the  time,  may  be  paid  the  death  benefit  to  which  he  is  entitled  and 
his  membership  cancelled,  (b)  In  connection  with  the  limitations 
mentioned  above,  it  must  be  remembered  that  these  societies  are  not 
mere  insurance  carriers.  Donations  are  frequently  made  in  cases  of 
disability  and  death  to  meet  problems  presented  when  claims  to  benefits 
have  been  satisfied.  In  other  words,  these  societies*  like  the  fraternal 
orders,  are  charitable  as  well  as  insurance  organizations.  Finally  (c) 
it  should  be  said  that  claims  may  not  be  made  for  sickness  benefits  in  the 
case  of  venereal  disease  or  disability  due  to  careless  or  immoral  conduct. 

The  administration  of  benefits  is  the  same  as  in  the  fraternals. 
Claims  may  be  made  only  for  disabling  sickness.  As  a  rule,  but  not  al- 
ways, claims  must  be  accompanied  by  a  physician^s  certificate,  and  the  sick 
are  visited  weekly  by  a  committee.  Where  a  second  claim  is  presented,  the 
member  may  be  visited  by  a  new  committee.  If  a  disabled  member  is 
absent  from  the  city,  statements  in  support  of  his  claim  have  to  be  sworn 
to  before  a  notary. 

Data  relating  to  the  number  of  claims  acted  upon  favorably  and 
the  amounts  paid  in  1917  were  obtained  from  84  societies  with  a  com- 
bined membership  of  11,377.  The  number  of  claims  paid  was  1506, 
the  amount  expended  in  sick  benefits  $32,328.77. 

Medical  Care  and  Hospital  Treatment. 

As  indicated  earlier,  most  of  the  independent  foreign  societies  limit 
themselves  to  the  payment  of  the  pecuniary  benefits  described  and  to 
charity  to  the  needy — in  so  far  as  their  activities  come  within  the  scope 
of  this  investigation.  However,  19  of  the  societies  with  a  membership 
of  2,545,  provide  for  medical  care  and  five  of  these  and  four  others  make 
provision  for  hospital  treatment  as  well.  The  medical  care  is  given  by 
the  "society  doctor."  The  general  rule  is  to-  collect  $1  a  year  from  each 
member  to  meet  the  expanse  involved.  In  some  cases  the  $1  per  member 
is  paid  to  the  doctor;  in  other  cases  he  is  paid  a  salary  from  a  fund  re- 
plenished by  assessment. 

One  Croatian  and  eight  Greek  societies  with  a  membership  of 
1,535,  were  found  which  have  made  provision  for  hospital  treatment. 
—34  H  I 


530 


The  arrangement  is  either  to  pay  all  hospital  bills  (two  Greeks  socie- 
ties) or  to  pay  so  much  per  week.  In  the  second  type  of  arrangement, 
from  $7  to  $15  per  week  is  allowed  for  six,  eight,  ten,  twelve,  twenty- 
six,  or  (in  three  cases)  an  idefinite  number  of  weeks. 

The  Undertaker,  Saloon-keeper  and  Doctor  as  Members.  §M 

Rather  prominent  as  members  of  the  foreign  societies  are  the^ 
undertaker,  the  saloon-keeper  and  the  doctor.  Though  they  may  take 
a  prominent  part  in  the  affairs  of  the  society,  it  is  not  to  be  concluded 
that  they  are  actuated  merely  by  business  motives.  While  business 
interests  have  something  to  do  with  the  matter,  another  factor  is  found 
in  the  place  they  occupy  in  the  community.  The  doctor  is  by  education 
a  leader;  the  undertaker  stands  out  prominently  in  the  group;  the 
saloon-keeper  is  likely  to  play  an  uncommonly  large  part  in  community 
affairs  because  the  saloon  carries  with  it  something  of  the  position  the 
inn  and  the  Gast-Haus  occupy  in  the  life  of  the  native  lands. 

The  Mortality  of  Foreign  Societies. 

An  effort  ha&  been  made  to  ascertain  the  death  rate  of  these 
foreign  societies,  but  without  much  success  because  of  the  absence  of 
earlier  lists  of  them  and  the  impossibility  of  compiling  such  lists  of 
earlier  societies  now.  It  has  been  learned  that  of  155  of  those  studied, 
13  were  organized  before  1890;  5  between  1890  and  1895;  17  between 
1895  and  1900;  27  between  1900  and  1905;  33  between  1905  and  1910; 
41  between  1910  and  1915;  and  19  in  1915  and  the  subsequent  years. 
This,  however,  shows  merely  that  a  majority  of  those  studied  have 
been  organized  during  the  last  thirteen  or  fourteen  years.  It  does  not 
assist  in  determining  how  many  have  ceased  to  be  independent  foreign 
societies  because  they  decayed  and  died  or  because  they  were  absorbed 
by  the  fraternal  orders.  Under  the  circumstances  one  must  rely  upon 
the  personal  knowledge  of  those  informed.  One  of  these  is  authority 
for  the  statement  that  of  125  societies  in  existence  25  years  ago  in  a 
certain  district  only  12  remain  today.  Such  statements  as  this  bear  out 
the  general  feeling  that  the  average  life  is  unfortunately  short.  No 
doubt  it  is  much  shorter  than  that  of  the  ordinary  fraternals  for  the 
factors  causing  the  foreign  society  to  disappear  are  more  numerous. 

Perhaps  the  most  important  cause  of  the  disappearance  of  foreign 
societies  as  such  is  their  absorption  by  fraternal  orders — a  matter 
already  mentioned.  What  were  independent  Polish,  Croatian,  Serbian, 
Slovak  and  Slovenian  societies  are  now  in  large  numbers  affiliated  as 
locals  with  national  fraternal  organizations.  In  this  case  the  insured 
gain  by  the  change  from  the  one  to  the  other  for  they  have  membership 
in  a  larger  and  more  stable  organization.  But,  unfortunately,  many 
decay  and  die. 

An  important  cause  of  the  frequent  decay  and  death  of  foreign 
societies  is  that  their  members  are  for  the  most  part  the  foreign  born. 
As  these  become  Americanized  they  may  lose  interest  in  the  society  and 
drop  their  membership.  Again,  the  centers  in  which  the  foreign  born 
settle  undergo  rapid  change.  A  given  race,  closely  settled  and  exten- 
sively organized,  sooner  or  later  scatters  and  perhaps  surrenders  its 
locality  to  another — the  society  decaying  and  disappearing  in  the  pro- 
cess.    Again,  the  native  offspring  do  not  generally  join  the  order  of 


531 

their  fathers.  Unless  there  is  a  movement  into  the  community  from 
the  outside,  there  is  not  the  needed  succession  of  young  lives.  The 
average  age  of  the  members  increases  and  the  risk  becomes  greater. 
Though  reserves  may  be  carried,  as  with  most  of  the  fraternals,  good 
insurance  principles  are  not  generally  observed;  the  dues  are  not  fixed 
so  as  to  cover  the  entire  life  of  the  existinp"  membership  and  prove  to 
be  more  or  less  inadequate.  Sooner  or  later  the  dues  or  the  assessments 
must  be  increased.  Other  younger  and  perhaps  better  managed  insti- 
tutions then  prove  more  attractive  to  those  eligible  to  membership.  The 
membership  declines  and  the  period  of  decay  sets  in.  This  course  has 
been  avoided  by  some  societies;  it  has  been  traversed  or  is  to  be  tra- 
versed by  a  larger  number. 

The  insurance  business  conducted  by  the  society  is  not  its  exclusive 
business;  frequently  it  is  the  less  important  part  of  it.  Naturally  be- 
cause of  this  and  the  small  size  of  the  organization  the  management  is 
usually  not  very  able.  Though  in  the  typical  case  considerable  care 
seems  to  be  exercised  in  the  management  of  affairs,  the  financial  officers 
"bonded"  and  the  books  more  or  less  well  audited,  the  handicap  re- 
mains. 

These  appear  to  be  the  chief  causes  of  the  mortality  and  sources  of 
weakness  in  the  foreign  society.  Of  course  some  of  the  investments 
prove  unsound  and  now  and  then  a  private  bank  in  which  the  funds 
may  have  been  deposited  has  failed  and  resulted  in  substantial  loss. 
These,  however,  have  been  the  less  important  factors  in  the  situation. 

The  Foreign  Societies  as  Insurance  Organizations. 

Little  need  be  said  in  addition  to  what  has  already  been  introduced 
incidentally  with  reference  to  these  foreign  societies  as  insurance  or- 
ganizations. 

First  of  all,  it  should  be  said  that  most  of  them  are  in  excellent^ 
position  to  meet  the  problems  of  malingering  in  connection  with  dis- 
ability benefits.  Moreover,  they  are  not  limited  to  the  terms  of  a 
definite  insurance  contract ;  like  the  fraternal  order  and  the  labor  union, 
they  can  and  frequently  do  extend  aid  where  there  is  no  claim  under 
the  benefit  rules.  Their  chief  shortcoming  is  in  their  instability  and  in 
their  voluntary  character.  This  defect  of  instability  is,  however,  of 
chief  concern  in  connection  with  the  death  benefits  promised.  Unfortu- 
nately all  too  frequently  the  expected  benefits  are  not  realized  because 
of  decay  and  death.  In  such  cases  the  insurance  proves  to  be  term 
insurance  with  premature  expiration.  It  is  relatively  inexpensive  and 
the  pecuniary  loss  is  not  great  because  of  the  small  sum  promised.  The 
loss,  however,  is  frequently  sustained  and  those  who  sustain  it  may  be 
handicapped  by  age  or  by  physical  defect  in  obtaining  insurance  with 
other  carriers.  If  the  societies  were  founded  on  good  insurance  prin- 
ciples, were  larger,  and  there  was  a  greater  guarantee  of  efficient  man- 
agement, their  value  would  be  distinctly  greater  because  of  a  more  suc- 
cessful appeal  to  those  eligible  to  membership  and  the  less  frequent 
cases  of  disappointment  and  loss. 


532 


SPECIAL  REPORT  XL     ESTABLISHMENT  FUNDS  IN 

ILLINOIS. 

(By  A.  E.  Suffern,  Pli.  D.) 


[Note  by  the  Secretary. — Special  Reports  XI  and  XII,  relating  to  Establishment 
Funds  and  Union  Benefit  Systems,  have  been  prepared  by  A.  E.  Suffern,  Professor 
of  Economics  in  Beloit  College.  Because  of  space  limitations  the  reports  are  pre- 
sented in  summary  form.  Though  an  effort  was  made  to  secure  complete  data 
from  employers  and  unions,  the  effort  was  not  entirely  successful.] 

The  study  of  establishment  funds  in  the  State  of  Illinois  as  a  part 
of  the  investigation  carried  on  by  the  Health  Insurance  Commission  has 
shown  that  they  are  one  of  the  most  important  means  of  providing  sick- 
ness and  other  benefits.  They  have  become  numerous  and  some  of  them 
have  provisions  which  compare  favorably  with  the  comprehensive  pro- 
visions ordinarily  embodied  in  national  compulsory  health  insurance 
schemes. 

Both  employers  and  employees  have  used  various  devices  for  meet- 
ing the  burden  of  sickness  and  death  among  the  workers.  Employers 
have  naturally  interested  themselves  in  the  relief  of  the  distress  of  their 
oldest  and  most  valuable  employees.  This  may  have  been  accomplished 
by  continuing  their  wages  for  a  certain  length  of  time,  a  practice  of  a 
not  inconsiderable  number  of  employers  at  the  present  time.  The 
employees  by  "passing  the  hat"  have  extended  relief  in  a  modest  way  to 
^their  comrades  in  cases  of  sickness,  accident  or  death.  This  frequently 
occurs.  But  in  a  large  number  of  cases  employers  and  employees  have 
come  to  appreciate  the  need  of  making  provision  in  a  systematic  way  and 
have  resorted  to  the  use  of  insurance  for  this  purpose.  More  and  more 
emphasis  has  been  placed  by  the  employers  upon  group  insurance*  which, 
however,  infrequently  covers  temporary  disability  caused  by  sickness. 
Of  more  importance  is  the  establishment  fund  by  which  regular  and 
systematic  provision  is  made. 

Various  studies  have  been  made  of  establishment  funds.  The 
features  of  a  particular  fund  have  frequently  been  a  subject  of  inquiry 
and  individuals  interested  in  taking  advantage  of  the  experience  of 
many  establishments  have  made  nation-wide  surveys.^  The  Federal 
Government  and  various  states  have  considered  them  of  sufficient  im- 
portance to  collect  extensive  information  relating  to  their  provisions  and 
operation.^ 

In  making  a  survey  of  provisions  against  sickness,  accident  and 
death,  the  Commission  sought  to  ascertain  the  number  and  operation 
of  establishment  funds  in  the  State  of  Illinois.     A  general  questionnaire 

»  The  most  Important  of  these  has  been  made  by  W.  L.  Chandler.     See  Industrial 
Management,  January  to  June,  1918. 

r«^«"/^^Q;?f^^^"^,i^®  J?^®r*^v''**^^  ^:^^^<'^  Report  of  the  U.  8.  Commissioner  of 
i2'o;'i.a'L'^i?i!Vgust.''r9n"'''  ""'^^'^^  ""'  ^'  ^^^«^*^«^*  of  Labor,  Bureau  of 


533 

was  sent  out  through  the  Illinois  Manufacturer's  Association  and  the 
Associated  Employers.  From  returns  thus  secured,  by  direct  communi- 
cations with  the  operators  of  public  utilities  and  mines,  and  through  per- 
sonal enquiry  and  correspondence  with  many  establishments  134  funds 
were  located.  It  is  likely  that  other  funds  could  be  found  in  the  State, 
but  it  is  probable  that  the  number  located  would  not  be  greatly  increased 
by  their  inclusion.  Of  the  134  found,  115  have  been  studied  in  detail, 
and  the  more  important  facts  have  been  reduced  to  a  comparable  basis 
and  made  a  matter  of  record  for  the    Commission. 

It  has  been  impossible  to  arrive  at  an  accurate  estimate  of  the 
number  of  wage-earners  in  Illinois  with  membership  in  establishment 
funds.  As  just  indicated,  not  all  of  these  funds  have  been  studied. 
Again,  a  considerable  number,  like  those  maintained  by  railroad  com-r 
panics,  are  interstate  in  their  operation  and  in  some  of  these  cases  it  has 
been  impossible  to  separate  the  membership  in  this  State  out  of  the  total. 
Finally'  in  a  few  cases  repeated  requests  for  information  needed  have  not 
met  with  the  desired  response.  Nevertheless,  it  can  be  said  that  the 
number  of  Illinois  wage-earners  with  membership  in  the  134  funds 
located  is  not  less  than  150,000  and  not  more  than  200,000.  This  is  be- 
tween 7^  and  10  per  cent  of  the  estimated  number  of  wage-earners 
in  the  State. 

As  would  be  expected,  the  extent  to  which  establishment  funds  are 
found  varies  greatly  from  one  industry  to  another  and  as  between  differ- 
ent parts  of  the  State.  If  laborers  are  organized  into  unions,  welfare 
plans  find  little  place  in  the  establishments  in  which  they  work.  Sick- 
ness, accident  and  death  benefits  are  likely  to  be  provided  by  the  union 
if  provided  at  all.  Only  the  larger  establishments  are  in  position  to 
make  satisfactory  and  systematic  provision  for  such  benefits  and  large 
scale'  business  is  found  chiefly  in  certain  industries  and  in  certain  parts 
of  the  State.  Again»  a  very  important  example  has  counted  for  much. 
If  one  prominent  establishment  sets  an  example,  the  other  establishments 
in  the  industry  or  in  the  locality  are  likely  to  follow  it.  For  Guch 
reasons  as  these  most  of  the  funds  found  are  in  the  iron  and  steel  plants, 
large  establishments  engaged  in  the  manufacture  of  agricultural  im- 
plements, the  meat-packing  plants  and  the  large  stores  of  Chicago,  or  are 
operated  by  the  railroad,  telephone  and  other  utility  companies.  They 
find  practically  no  place  in  coal  mining  and  the  building  trades  where 
the  men  are  well  organized  into  unions,  and  in  the  many  industries  and 
businesses  conducted  on  a  small  scale. 

The  organization  of  establishment  funds  has  gained  impetus  within 
the  last  few  years.  Yet  the  scheme  is  by  no  means  a  new  one.  No 
fewer  than  twenty  of  the  115  studied  have  been  in  operation  for  twenty 
years  or  more>  and  one  of  these  has  been  in  operation  since  1874.  While 
a  number  of  the  funds  have  been  in  operation  for  a  good  many  years, 
•it  is  important  to  note  that  most  of  those  located  have  been  started 
within  the  last  eight  or  ten  years,  and  that  the  list  is  being  added  to 
yearly. 

While  new  funds  have  been  organized,  a  considerable  number  have 
been  discontinued  for  one  or  more  of  several  reasons.  In  some  instances 
the  opposition  of  employees  who  had  established  a  union  has  caused  the 


534 

lapsing  of  a  fund.  A  few  cases  have  been  found  where  unions  have 
been  formed  and  made  provision  for  disability  and  death  benefits  and 
the  men  have  objected  to  two  systems  of  insurance.  Or  it  may  be  that 
the  employer,  confronted  by  union  demands,  has  changed  his  labor 
policy  and  given  up  his  welfare  plans.  Some  funds  were  discontinued 
when  Workmen's  Compensation  was  adopted  and  the  old  provision  for 
cases  of  industrial  accident  was  no  longer  needed.  Finally,  to  mention 
only  the  more  important  causes,  some  have  been  discontinued  because  the 
benefits  expected  have  not  been  realized. 

As  already  stated,  detailed  information  has  been  secured  from  115 
of  the  134  establishment  funds  known  to  exist  in  the  State.  The  details 
show  a  bewildering  variety  in  membership  rules,  in  benefits  provided, 
in  method  of  support  and  in  administration.  In  some  cases  member- 
ship is  compulsory,  in  others  voluntary.  Where  voluntary,  the  rules 
relating  to  admission  may  be  restrictive  or  fairly  free  from  limitations. 
Collectively  they  compensate  for  wages  lost  by  reason  of  disabling  sick- 
ness or  accident,  provide  funeral,  benefits  and  life  insurance*  and  make 
organized  provision  for  medical  and  surgical  treatment,  hospital  care, 
nursing,  medical  and  surgical  supplies,  and  dental  care.  Thus  every 
feature  of  a  fuU-fiedged  health  insurance  program  is  found.  But  taken 
separately  in  no  case  are  all  of  the  benefits  thus  enumerated  provided. 
In  most  cases  only  cash  benefits  are  paid,  frequently  in  small  sums  for 
a  comparatively  short  time;  in  only  a  few  cases  are  extensive  medical* 
nursing  and  dental  benefits  found.  In  some  cases  the  entire  cost  is 
borne  by  the  employees;  in  some  cases  it  is  divided  in  some  proportion 
or  other  between  them  and  the  firm ;  while  in  still  other  cases  it  is  borne 
entirely  by  the  employers.  The  administration  may  be  in  the  hands  of 
the  employees,  in  the  hands  of  the  employer,  or  be  shared  in  or  con- 
trolled by  both.  The  details  relating  to  membership,  benefits,  method 
of  support,  and  experience  are  presented  at  some  length  in  the  later 
sections  of  this  report. 

The  widely  varying  arrangements  found  among  the  funds  studied 
are  easily  understood,  for  these  funds  are  the  result  of  initiative  taken 
by  employer,  employees,  or  employer  and  employees  to  meet  differeing 
situations  by  rule  rather  than  by  "passing  the  hat"  or  by  continuing 
wages  to  a  part  of  those  who  fall  ill.  In  the  absence  of  compulsion 
and  standardizing  agency,  some  funds  have  been  like  Topsy — just 
"growed;"  others  have  been  worked  out  with  some  care;  still  others 
are  the  product  of  past  experience;  many  have  been  copied  with  or 
without  serious  revision;  and  how  much  it  would  cost  has  usually  been 
a  consideration  of  importance. 

While  the  establishment  funds  studied  present  the  greatest  varia- 
tions in  detail,  they  are  after  all  of  three  main  types,  which  may  be 
called  employees',  joint,  and  employers'  funds. 

Those  in  which  the  support  is  entirely  provided  by  the  employees 
may  be  designated  as  Employees  Establishment  Funds.  Generally  the 
administration  of  these  is  completely  in  the  hands  of  the  employees. 
Where  these  two  characteristics  are  present,  but  in  conjunction  with 
which  the  dues  are  collected  by  the  firm  from  the  pay-roll,  the  basis 
has  been  laid  for  what  may  be  properly  termed  Joint  Establishment 


^  o  r* 


Funds.  The  firm  in  functioning  thus  as  a  collector  of  dues  has  defi- 
nitely taken  on  one  of  the  chief  items  of  expense  in  the  administration 
of  the  fund,  and  this  service  may  rightly  be  counted  as  a  contribution 
to  the  fund.  From  this  point  it  is  only  a  matter  of  elaborating  the 
assistance  which  the  firm  may  give  in  administering  claims,  sharing  in 
the  joint  official  responsibilities,  and  in  making  definite  money  contri- 
butions to  the  fund  each  year.  When  these  features  are  present,  we  have 
what  is  ordinarily  thought  of  as  Joint  Establishment  Funds  in  the 
fullest  sense  of  the  term.  Of  those  studied  22  may  be  classed  as  Em- 
ployees Funds  and  82  as  Joint  Funds. 

In  the  third  type,  here  called  the  Employer's  Fund,  and  totalling 
11,  the  employer  makes  the  entire  contribution  to  the  fund  and  has 
charge  of  the  administration  of  it.  Under  such  circumstances  the 
burden  of  sickness,  as  in  the  case  of  insurance  against  accidents  under 
the  workmen's  compensation  laws,  becomes  a  charge  upon  the  business. 

As  illustrative  of  the  nature  of  establishment  funds  one  of  each 
type  has  been  selected  and  the  main  provisions  are  set  forth.  An  em- 
ployees' fund  with  a  membership  of  38,  provides  a  sickness  benefit  only. 
The  fund  is  supported  by  contributions  from  members  of  50  cents  per 
month.  There  is  a  waiting  period  of  14  days  before  members  are  en- 
titled to  benefits,  but  if  sickness  continues  beyond  this  fixed  period, 
benefits  are  "naid  from  the  first  day  of  sickness.  The  fund  provides  $10 
per  week  for  13  weeks  for  any  one  disability  and  a  maximum  of  39 
weeks  in  any  one  year.  No  medical,  hospital,  or  nursing  care  is  pro- 
vided, nor  is  any  funeral  or  death  benefit  paid. 

Over  against  this  voluntary  fund  administered  entirely  by  the 
employees  may  be  placed  an  employers'  fund,  membership  in  which  is 
compulsory.  The  total  number  of  employees  covered  is  6,975.  The 
entire  support  is  borne  by  the  employer  and  the  fund  is  managed  as  a 
regular  part  of  the  business.  The  waiting  period  is  3  days  and  the 
benefits  begin  on  the  fourth  day  of  disability.  The  fund  provides  a 
benefit  of  two-thirds  wages  for  a  period  of  10  weeks.  In  addition  to  the 
sickness  benefit  a  death  benefit,  that  increases  from  $500  to  $1,000  with 
length  of  service,  is  paid.  Medical  treatment  is  furnished  at  the  plant 
and  is  also  frequently  extended  to  the  home  of  the  members.  Hospital 
care  is  frequently  furnished  when  there  is  urgent  need.  Two  nurses 
are  provided  at  the  plant,  but  no  definite  arrangements  are  made  for 
visiting  nurses.  Dental  care  is  confined  to  examination  and  advice. 
The  firm  maintains  a  pension  fund  for  the  employees  and  for  widows 
of  former  empoyees  in  addition  to  its  care  of  sickness. 

Between  these  two  types  a  joint  fund  has  been  chosen  in  which  the 
management  is  shared  by  employer  and  employee.  The  one  chosen  for 
study  had  in  1917  a  membership  of  26,759  in  23  plants.  It  provides 
a  waiting  period  of  7  days.  Benefits,  beginning  on  the  eighth  day,  are 
paid  for  52  weeks.  The  amount  of  the  benefit  is  one-half  wages. 
Medical  care  is  confined  to  the  plant.  One  nurse  is  employed  at  each 
of  the  plants  and  in  one  locality  arrangements  are  made  with  a  Visiting 
Nurse  Association  to  visit  employees  at  their  homes  when  needed.  A 
death  benefit  of  1  years'  wages  with  a  maximum  of  $2,000  in  case  of 
sickness,  and  2  years'  wages  in  case  of  accident,  is  paid.  The  fund  pays 
a  maternity  benefit  of  3  months'  earnings  to  those  who  have  been  mem- 


536 


bers  for  a  period  of  9  months.  To  the  support  of  these  benefits  the  firm 
contributes  a  definite  lump  sum  and  assists  in  the  management  of  the 
fund.  In  addition  to  the  above  benefits,  tuberculosis  cases  promising 
beneficial  results  receive  sanatorium  treatment  in  excess  of  the  52  weeks 
provided  by  the  fund.  The  support  of  the  treatment  is  divided  equally 
between  the  firm  and  the  fund — the  fund  charging  its  share  to  "ex- 
pense" rather  than  to  benefits. 

I.  Membership, 

Eleven  of  the  115  funds  studied  are  maintained  by  the  employers. 
In  these  cases  all  of  the  employees  who  can  meet  the  qualifications  set 
up  have  membership  in  the  funds.  The  same  is  true  of  the  18  joint 
funds  in  which  membership  is  compulsory.  In  several  other  cases  the 
pressure  brought  to  bear  upon  workmen  to  seek  membership  is  so  great 
that  little  option  is  left.  Combining  these  cases,  a  considerable  number 
of  instances  are  found  in  which  all,  or  all  but  a  comparatively  few  of 
the  employees  are  insured.  Over  against  these  stand  the  larger  number 
of  funds  in  which  membership  is  purely  voluntary.  Whether  the  mem- 
bership in  these  funds  is  relatively  large  or  small  depends  upon  num- 
erous factors  such  as  the  interest  displayed  in  securing  new  members, 
the  terms  on  which  they  may  secure  benefits,  the  nature  of  the  benefits, 
and  other  opportunities  available  for  insurance.  The  investigation 
shows  precentages  of  membership  varyinp*  all  the  way  from  close  to  100 
down  to  24  per  cent.  Taking  88  funds  of  the  various  types  together, 
it  was  found  that  the  membership  was  65  per  cent  of  the  total  number 
of  employees. 

Great  importance  attaches  to  the  qualifications  for  or  restrictions 
upon  membership.  The  more  important  of  these  are  summarized  in 
Table  I. 


TABLE    I— MEMBERSHIP    IN    ESTABLISHMENT    FUNDS. 


• 

o 

3 

a 

3 

:25 

Limitations  on  admission. 

Membership  lost 
because  of— 

Dependents 
admitted 
to  member- 
ship. 

Type  of  fund. 

o 

< 

a  cA 

dX3 

1 

a 

03 

«    . 
©  n 

ll 

Period  of  em- 
ployment. 

1 

§ 

..-4 

03 

•a 

Branch  of  em- 
ployment. 

Salaried 
employees. 

02 

s 

a 
0 

•^  3 

ft 

i 

03 

03 
ft 

■•-> 

a  3 

a§ 

a" 
t— 1 

a 

i 

0 

Employees 

22 
11 
82 

4 

1 

21 

11 

2 

42 

2 
0 
9 

7 

4 

26 

12 

5 

31 

16 

0 

33 

1 
0 
3 

6 
'"2 

0 
1 
5 

2 
0 
3 

20 

0 

47 

6 

8 
58 

14 
10 

77 

10 

8 
31 

1 
0 
3 

1 
0 
2 

EmDloyers 

Joint...........:::: 

Total 

115 

26 

5,5 

11 

37 

48 

49 

4 

8 

6 

5 

67 

72 

101 

49 

4 

3 

This  table,  based  upon  an  analysis  of  the  constitutions  and  by-laws 
of  establishment  funds,  shows  that  a  great  variety  of  conditions  are  set 
up  for  membership.  Few  cases  are  found  in  which  a  number  of  limita- 
tions are  not  present,  and  in  some  instances  they  are  decidedly  restric- 
tive in  their  effects. 


537 

The  most  frequent  qualifications  ioT  membership  are  with  reference 
to  age  and  personal  habits.  Most  of  the  age  limitations  are  designed 
to  debar  the  older  men  from  securing  membership  and  drawing  upon 
the  funds  greatly  in  excess  of  the  contributions  they  make  to  them. 
For  the  same  reason  the  rules  in  approximately  half  of  the  cases  provide 
specifically  for  the  exclusion  of  those  of  immoral  habits.  The  passing  of 
a  medical  examination  is  another  protective  device  found  in  almost  a 
third  of  the  funds.  Incidentally  it  excludes  those  most  in  need  of  the 
benefits  provided.  Following  lodge  practice,  initiation  fees  are  charged 
in  many  cases  (49).  In  a  few  cases  certain  races  are  barred  from  mem- 
bership. In  a  very  few  instances  restrictions  prevent  the  admission  of 
salaried  workers  (6  cases)  or  those  whose  earnings  fall  below  a  certain 
amount  (5).  In  the  one  case,  it  may  be  claimed  that  those  with  large 
earnings  are  individually  able  to  take  care  of  sickness,  while  in  the 
other  the  benefit  may  exceed  the  wage  of  the  employee  and  thus  encour- 
age malingering. 

Restrictions  based  upon  the  length  of  service  and  on  physical  con- 
dition as  shown  by  a  medical  examination  have  become  increasingly 
important.  Even  in  the  voluntary  associations  a  period  of  probation 
may  be  set  up  by  the  older  employees  in  the  association  in  order  to 
discover  what  sort  of  risk  a  new  employee  promises  to  be,  before  he  is 
admitted  to  membership.  For  the  employer  a  period  of  probation  serves 
two  purposes.  By  this  means  he  is  freed  from  risk  of  sickness  benefits 
arising  in  connection  with  the  casual  and  shifting  body  of  his  employees. 
And,  in  the  second  place,  the  promise  of  benefits  after  a  period  of  faith- 
ful service,  may  result  in  longer  tenure,  thereby  reducing  his  labor  turn- 
over and  increasing  the  efficiency  of  his  force.  In  the  employer's  funds 
studied  the  period  of  probation  ranged  from  3  months  to  2  years,  while  in 
the  employees'  and  joint  funds  it  ranged  from  1  week  to  3  months,  the 
most  common  period  being  one  month.  Of  the  104  employees'  and  joint 
funds  43  fixed  the  period  of  probation  at  one  month. 

The  importance  of  medical  examination  as  a  form  of  restriction  is 
seen  in  its  use  by  7  of  the  22  employees'  funds,  by  4  of  the  11  em- 
ployers' funds  and  by  26  of  the  82  joint  funds.  Medical  examination 
may  be  used  not  only  as  a  means  of  eliminating  chronics  as  a  drain  on 
the  fund  but  it  may  also  be  used  to  prevent  a  drain  from  the  appearance 
of  contagious  diseases.  Its  importance  as  a  means  of  restricting  mem- 
bership can  not  be  judged  solely  by  the  number  of  funds  that  have  this 
specific  provision. 

A  numebr  of  establishment  funds  were  found  in  connection  with 
firms  that  required  a  physical  examination  as  a  condition  of  employ- 
ment. Where  funds  are  so  situated,  there  has  already  been  a  selection 
of  workmen  on  the  basis  of  health  and  physical  fitness.  Instead  of  a 
medical  examination  as  a  condition  of  membership,  the  annlicant  may 
be  required  to  file  a  health  certificate  from  the  employment  department. 
If  the  fund  provides  an  additional  medical  examination,  it  means  that 
a  further  selection  is  made  and  the  sickness  experience  of  such  funds 
can  not  be  taken  as  a  basis  for  conclusions  that  will  apply  to  workmen 
generally. 


538 

While  rules  restricting  membership  in  some  form  appear  in  almost 
all  of  the  funds  studied,  there  has  been  no  means  of  estimating  the 
extent  to  which  they  have  actually  limited  admission  to  them. 

Along  with  the  restrictive  rules  there  may  be  also  pressure,  especi- 
ally in  employee  and  voluntary  joint  funds,  to  include  as  large  a  number 
of  members  as  possible.  Funds  in  small  plants  providing  few  and 
meagre  benefits  may  be  successfully  operated  with  voluntary  member- 
ship. But  as  more  elaborate  and  adequate  benefits  are  provided,  the 
expense  of  operation  becomes  increasingly  heavy.  The  desire  to  reduce 
the  burden  of  this  expense  and  thereby  protect  the  amounts  available 
for  benefits  is  a  strong  force  in  extending  the  membership  to  include 
as  large  a  number  as  possible. 

After  an  employee  has  been  admitted  to  a  fund,  he  may  lose  his 
membership  as  the  result  of  a  variety  of  stipulated  penalties.  Failure 
to  pay  dues  is  followed  by  loss  of  membership  in  67  of  the  104  employee 
and  Joint  funds  studied.  As  soon  as  membership  becomes  compulsory 
or  when  the  dues  are  deducted  from  the  pay  roll,  there  is  no  occasion 
for  the  use  of  this  penalty. 

Immoral  conduct  is  another  cause  which  may  result  in  loss  of  mem- 
bership. What  constitutes  immoral  conduct  is  different  in  nearly 
every  association  that  has  adopted  this  provision.  However,  it  is  of 
enough  significance  to  appear  in  the  constitutions  of  49  of  the  115 
funds.  Fraud,  giving  false  information  and  disobedience  of  the  rules 
of  the  association  may  be  cited  as  causes  which  may  call  forth  this 
penalty. 

A  *^ay  off^'  and  discharge  are  usually  followed  by  loss  of  member- 
ship. In  72  of  the  funds  studied,  a  "lay  off,"  and  in  101  discharge 
would  call  forth  this  penalty.  But  in  some  instances  the  penalty  is 
tempered  by  allowing  the  employee  to  retain  his  rights  to  benefit  for  a 
period  of  time  by  keeping  up  the  payment  of  his  dues.^  Provisions  for 
the  retention  of  these  rights  by  discharged  workmen  are  not  likely  to 
find  favor  among  the  members  of  these  funds,  for  employees  engaged 
in  another  occupation  may  introduce  another  degree  of  risk  to  sickness. 
For  this  reason  and  because  protection  against  sickness  is  regarded  as 
the  affair  of  a  particular  establishment,  such  provisions,  are  not  likely 
to  become  prevalent. 

When  an  employee  has  lost  his  membership  for  one  reason  or  an- 
other, provision  for  reinstatement  upon  the  payment  of  a  fee  is  found  in 
18  funds.  These  fees  range  from  25  cents  to  $10 — the  majority  being 
about  one  dollar. 

Sickness  henefits. — The  sickness  benefits  paid  are  in  some  instances 
fixed  in  amount  while  in  others  they  vary  with  amount  of  salary,  length 
of  service,  number  of  weeks  the  benefits  are  paid,  or  in  accordance  with 
some  other  standard.  Fixed  benefits  are  accompanied  by  fixed  dues, 
and  graded  benefits  by  graded  dues.  These  facts  are  shown  in  Tablell. 
In  63  of  the  funds  fixed  benefits  are  paid  and  these  range  from 
$4.06  to  $14  per  week.  The  majority  of  them  paid  $7  to  $10  per  week. 
In  57  of  the  funds  graded  benefits  were  paid  which  ranged  from  $1.50 

•The  most  striking  case  found  permitted  the  retention  of  membership  for  one 
year  upon  the  payment  of  dues. 


539 


to  $19.98  per  week.     In  a  majority  of  the  cases  the  minimum  benefits 
are  close  to  $3.50  per  week  and  the  maximum  about  $11.50. 

TABLE     II— RATES     OF     WEEKLY     ACCIDENT     AND     SICKNESS     BENEFITS 
CLASSIFIED   ACCORDING    TO    TYPES    OF    FUNDS. 


vi 

^ 

Fixed  rates 

.* 

Graded  rates.* 

c3 

t3 

Si 

O 

X 

T3 

to 

Accident. 

Sickness. 

Accident. 

Sickness. 

-fj 

.c 

-^ 

Type  of  fund. 

© 

% 

£s 

8 

R 

R 

Mini- 

Maxi- 

Mini- 

Maxi- 

^ 

en 

S 

-^ 

R 

R 

^ 

mum. 

mum. 

mum. 

mum. 

fl 

•c 

-o 

5£ 

3 
o 

8 

<^ 

ni 

CO 

la 
o 

— ,  © 

C  ^" 

o 

s 

o 

8 

o 

c 

S 

O 

8 

2 

c 

Of-" 

8o^ 

1^ 

2s 

8o> 

H 

^ 

£h 

t^ 
«# 

^ 

^ 

fe 

«« 

^ 

4^ 

^ 

s^ 

^ 

^ 

Employees 

?? 

18 

4 

5 

4 

7 

.5 

5 

8 

1 

1 

1 

1 

1 

3 

2 

2 

Emcloverst  

11 

1 

fio 

1 

1 

Joint 

82 
115 

t44 

16 

9 



23 

16 

2 

14 

16 

13 

16 

14 

16 

14 

16 

Total 

63 

**51 

22 

13 

7 

29 

21 

10 

15 

17 

14 

17 

15 

19 

J6 

18 

*  These  "Fixed  Rates"  are  variable  in  amount  only  as  between  funds  while 
"Graded  Rates"  are  variable  in  amount  within  the  same  fund  as  well  as  between 
funds.  The  data  under  these  headings  are  merely  a  tabulation  of  details  where 
given.  The  variation  in  totals  from  the  general  totals  is  due  to  the  fact  that  not 
all  funds  provide  accident  benefits  and  that  detailed  information  on  graded  rates 
was  not  given  in  every  case. 

t  All  of  the  Employers  funds  except  one  were  graded  in  rate  benefits  according 
to  amount  of  salary,  length  of  service,  and  number  of  weeks  benefits  were  paid. 

$  Benefits  consisted  of  medical  care  among  three  hospital  funds  and  are  not 
included  in  the  figures  for  the  rates  of  benefits.  One  joint  fund  did  not  report 
benefits. 

*  Six  joint  funds  provided  percentages  of  wages  for  variable  periods.     One  joint 
fund  did  not  report  benefits. 

The  statement  of  the  benefits  paid  raises  the  question  of  their 
adequacy.  The  need  of  the  wage  earner  and  his  dependents  is  even 
greater  in  time  of  sickness  than  in  health.  But  in  determining  the 
amount  he  shall  receive  and  how  soon  he  shall  get  it,  the  possibility  of 
malingering  must  be  considered.  Testimony  has  been  given  by  one  who 
has  had  large  experience  that  sickness  beneiits  may  be  as  high  as  90 
per  cent  of  the  wages  and  still  not  encourage  malingering.*  This  state- 
ment is  corroborated  by  the  experience  of  employers'  funds  which  pay 
full  wages  for  a  certain  length  of  time.  Of  course  such  a  provision  is 
supplemented  by  an  effective  system  of  administration  which  enables 
a  firm  to  check  up  absence  and  sickness  of  its  employees. 

The  establishment  of  a  waiting  period  before  a  sick  member  is 
entitled  to  benefits  is  an  additional  check  on  malingering.  The  wait- 
ing period  found  in  connection  with  the  funds  studied  varies  from  half 
a  day  to  14  days,  but  the  most  common  period  is  7  days.  Three  funds 
had  no  waiting  period,  one  had  one-half  day,  one  had  1  day,  two  had 
3  days,  three  had  6  days,  twentyseven  had  7  days,  and  three  had  14 
days.^  There  is  also  a  difference  in  the  practice  as  to  whether  the  bene- 
fits date  from  the  first  day  of  sickness  or  from  the  end  of  the  waiting 
period.     There  were  38  funds  in  which  benefits  are  paid  from  the  first 

*  Chandler,  Industrial  Management,  April,  1918,  p.  293. 
^  See  Table  III. 


540 

day  of  sickness,  but  the  most  common  practice  is  to  pro\ide  benefits 
from  the  end  of  a  7  day  waiting  period.  Forty  of  the  115  funds  showed 
disability  from  sickness  and  compensation  during  the  year.  Of  this 
number  13  pay  benefits  from  the  first  day  of  sickness,  providing  the 
sickness  lasts  for  the  stipulated  waiting  period.^  Eleven  of  these  13 
funds  are  joint  funds  and  2  employees'  funds.  Certainly  an  employee 
is  less  apt  to  pretend  to  be  sick  if  he  does  not  receive  pa3^ment  for  the 
waiting  period.  If  he  does  receive  payment  he  is  likely  to  remain  away 
from  work  a  day  or  two  longer  to  fill  out  the  time  necessary  .to  receive 
benefits.  The  only  way  such  contingency  could  be  dispensed  with  would 
be  to  provide  a  very  efficient  system  of  medical  examination  which 
would  compel  the  employee  to  return  to  work  as  soon  as  he  is  able. 
Much  the  same  problem  of  administration  is  present  when  the  waiting 
period  is  two  or  three  days,  and  even  fixing  the  payment  of  benefits  from 
the  end  of  the  waiting  period  does  not  entirely  dispense  with  this 
problem. 

On  the  other  hand,  the  requirements  in  connection  with  the  waiting 
peripd  may  be  so  stringent  as  to  deprive  the  member  of  the  protection  he 
needs.  A  14  day  or  longer  waiting  period  will  eliminate  a  large  per- 
centage of  the  cases  of  sickness.  This  objection  to  a  long  waiting  period 
is  offset  by  some  associations  by  the  payment  of  the  regular  benefit  from 
the  beginning  of  the  period  or  the  pa}Tnent  of  from  $1  to  $3.50  for  the 
first  week  of  the  waiting  period  and  the  regular  benefit  for  the  second 
week  and  thereafter. 

Another  problem  is  the  number  of  weeks  a  member  may  receive 
benefits  during  any  disability,  and  in  any  one  year.  The  rules  governing 
these  questions  have  a  very  important  bearing  upon  the  extent  of  the 
protection  the  member  receives  and  upon  the  solvency  of  the  fund.  Tak- 
ing all  of  the  funds  into  consideration,  the  number  of  weeks  that  benefits 
are  paid  for  any  one  disability  varies  from  2  to  104,  but  the  length  of 
time  most  commonly  found  is  13  weeks.'^  When  the  benefits  are  paid 
for  a  period  of  only  13  weeks  cases  of  prolonged  illness  can  not  be  properly 
cared  for.  Nor  is  a  member  better  off  w^hen  the  rules  provide  benefits 
for  a  stated  number  of  weeks  in  one  year,  unless  there  is  a  very  liberal 
provision  to  take  care  of  sicknesses  of  long  duration.  Among  12  funds 
an  attempt  has  been  made  to  care  for  prolonged  disability  by  providing 
benefits  for  52  weeks,^  and  in  some  of  these  provision  is  made  for  an 
extension  of  benefits  at  the  discretion  of  a  board  of  directors  or  officials. 
Of  those  funds  that  make  provision  for  a  rather  limited  period  for  a 
given  disability  or  for  disability  in  any  one  year,  43  claim  to  make 
further  extensions  of  benefits  in  special  cases.  Unfortunately,  there  is 
no  record  of  the  adequacy  of  such  extensions  but  apparently  when  pro- 
vision  is  made  the  benefits  paid  are  usually  at  a  greatly  reduced  rate. 

The  benefits  paid  by  employers'  funds  are  often  governed  by  the 
length  of  employment  with  the.  firm  and  the  amount  of  wages  or  salary 
received.  The  simplest  arrangement  provides  for  full  or  half  salary  for 
a  fixed  period.     In  others  the  greater  the  length  of  service  up  to  a 

•  See  Table  III.  p.  542. 

» The  actual  distribution  was  as  follows :  one,  4  weeks ;  three,  6  ;  one,   7  ;  five, 
^"'  V^  12:  thirteen,  13  ;  one,  14  ;  two,  15;  one.  17;  six,  26  and  five,  52  weeks. 
»  These  firms  provide  benefits  for  104  weeks. 


541 

certain  number  of  years,  the  longer  the  employee  may  draw  benefits. 
The  most  liberal  provision  for  aid  in  case  of  prolonged  sickness  found 
among  the  employer's  funds  studied  is  a  guarantee  of  half  salary  until 
the  employee  is  able  to  resume  work. 

There  is  a  great  variety  of  rules  governing  the  payment  of  benefits 
in  case  of  chronic  diseases.  Where  there  is  no  medical  examination  as 
a  condition  for  membership,  there  are  usually  lax  arrangements  for  the 
payment  of  benefits.  This  situation  is  likely  to  be  found  among  em- 
ployees' funds.  Out  of  32  employees'  associations  17  pay  benefits  in  cases 
of  chronic  diseases.  However,  the  burden  upon  the  fund  from  this  pro- 
vision is  generally  greatly  lessened  by  the  limitation  upon  benefits  for 
any  one  disability,  or  in  any  one  year.  The  same  statement  is  true  for 
the  30  joint  associations  that  provide  for  chronic  cases,  except  among 
those  which  allow  for  an  extension  of  benefits.  Only  3  of  the  employers' 
funds  pay  for  chronic  diseases  but  4  out  of  11  have  provision  for  ex- 
tension of  benefits.  Six  of  the  22  employees'  associations  and  33  of 
the  82  joint  associations  allow  extension  of  benefits. 

In  order  to  show  the  operation  of  these  funds  it  will  be  well  to  con- 
sider briefiy  the  provisions  for  sickness  among  the  40  funds  that 
furnished  information  concerning  the  number  of  employees,  the  number 
of  members,  the  members  receiving  benefits,  the  extent  of  disability,  the 
compensation  paid  and  the  cost  per  member.  ^  For  the  year  1917  (the 
last  year  for  which  complete  data  could  be  obtained)  there  were  be- 
tween 314,000  and  320,000  employees  in  the  establishrdents  where  these 
40  funds  were  located.^  The  membership  in  these  funds  was  228',880. 
During  the  year  there  were  55,  467  cases  of  disability  compensated,  or  1 
for  each  4.1  members.  The  number  of  days  of  disability  compensated 
was  1,265,846,  or  22.8  days  per  case.  Very  few  firms  could  furnish 
information  concerning  the  total  days  of  disability  of  their  employees  as 
no  records  were  kept  for  the  time  lost  that  did  not  result  in  the  granting 
of  benefits.  Only  those  firms  which  had  no  waiting  period,  and,  there- 
fore, compensated  for  all  time  lost  could  state  total  disability  due  to 
sickness,  and  as  there  were  only  3  such  funds,  conclusions  based  on  their 
experience  would  be  of  little  value.  The  benefits  paid  in  the  above  cases 
amounted  to  $1,653,619  or  $29.91  per  case,  which  is  equivalent  to  $1.31 
per  day  of  disability.  If  the  costs  of  these  benefits  are  spread  over  the 
entire  membership,  it  would  amount  to  $7.22  per  member. 

However,  these  averages  must  be  used  with  great  caution  and  con- 
sidered in  the  light  of  the  various  influences  that  affect  them.  The 
amount  of  benefits  paid,  and  therefore  the  averages,  depend,  as  already 
indicated,  upon  the  duration  of  sickness,  the  rate  of  benefits,  the  waiting 
period,  the  grading  of  benefits,  and  other  similar  influences.  While 
these  figures  are  unsatisfactory  for  showing  sickness  experience,  they  are 
of  interest  in  the  light  they  throw  on  the  amount  and  adequacy  of  the 
care  of  sickness  through  establishment  funds. 

Provision  for  maternity  benefit  is  found  in  nine  employees'  funds, 
in  5  joint  funds  and  in  1  employers'  fund. 

*  See  Table  III.  Some  of  these  establishments  were  doing  an  interestate  busi- 
ness, and,  therefore,  the  figures  include  employees  outside  of  the  State.  The  number 
of  employees  was  not  reported  for  five  establishments,  although  the  membership 
in  the  funds  was  given.  In  the  35  remaining  establishments  there  were  314,032 
employees. 


542 


TABLE   III- 


-SHOWING   DETAILS    FOR    40    FUNDS    CLASSIFIED    BY    LENGTH 
OF    WAITING    PERIOD. 


en 

>, 

eS 

•O 

c 

•^^ 

Num- 

•s 

ber  of 

.^4 

fund. 

0) 

P. 

M 

5 

■w 

•a 

^ 

Benefit 
begins. 


"S 


CO 

O 


B 


a 
a 


XI 

a 


XI 


S 


X3   . 


Days  of  disability. 


(3 
O 


en 

a 
o 

03 

ID 
> 


Si 

^a 

>  9 
<1 


Benefits  paid. 


03 
O 


o 

K 

03 
o 

(.1 
« 

ft 

<o 

tc 

03 

<s 

> 


(1 

P* 


o    . 

^a 
^a 


1 

0 

2 

0 

3 

0 

4 

* 

5 

1 

6 

3 

7 

3 

8 

6 

9 

6 

10 

6 

11 

7 

12 

7 

13 

7 

14 

7 

15 

7 

16 

7 

17 

7 

18 

7 

19 

7 

20 

7 

21 

7 

22 

7 

23 

7 

24 

7 

25 

7 

26 

7 

27 

7 

28 

7 

29 

7 

30 

7 

31 

7 

32 

7 

33 

7 

34 

7 

35 

7 

36 

7 

37. 

7 

38 

14 

39 

14 

40 

14 

1st  day.. 

..do 

..do — . 

..do 

..do 

4th  day. 

..do 

7th  day. 

..do 

..do 

8th  day. 

..do 

..do 

..do 

..do 

..do 

..do.... 
1st  day.. 
8th  day. 

..do 

1st  day.. 
8th  day. 
..do. . .. 
1st  day.. 

..do 

8th  day. 

..do 

..do 

..do 

1st  day.. 

..do 

8th  day. 

..do 

1st  day.. 
8th  day. 
1st  day.. 

..do 

15th  day 
1st  day.. 
..do 


52 

325 

190 

49 

601 

12.2 

3.16 

10 

tt 

375 

60 

3,108 

51.8 

8.28 

6 

130 

125 

42 

462 

11.0 

3.69 

7 

65 

40 

57 

172 

3.0 

4.30 

14 

709 

293 

138 

2,243 

17.3 

17.62 

13 

4,935 

1,014 

445 

1,290 

2.8 

1.27 

10 

16,033 

5,342 

1,943 

25,444 

15.9 

4.78 

52 

73,446 

53,385 

12, 420 

432,791 

47.6 

8.10 

52 

71, 162 

J54,130 

133,615 

J399,050 

19.3 

7.37 

53 

47,349 

39,690 

4,608 

124,687 

24.8 

4.19 

**13 

293 

293 

5 

24 

3.4 

.08 

ttl3 

319 

319 

5 

440 

95.0 

1.37 

*13 

106 

106 

17 

438 

32.4 

4.07 

♦13 

29,095 

29,095 

1,142 

31,884 

34.4 

1.09 

♦13 

15,043 

15,013 

2,960 

98,312 

40.0 

5.53 

26 

■t 

43 

10 

296 

29.6 

6.90 

26 

■t 

392 

26 

641 

30.6 

1.63 

6 

1,250 

1,250 

253 

3,501 

13.8 

2.80 

13 

5^ 

56 

15 

173 

17.5 

3.09 

12 

175 

70 

15 

554 

36.9 

7.91 

13 

715 

290 

31 

993 

32.0 

3.42 

13 

105 

40 

2 

26 

13.0 

.65 

13 

715 

274 

32 

912 

28.5 

3.32 

10 

300 

270 

29 

460 

20.6 

1.70 

17 

140 

77 

36 

569 

15.8 

7.32 

13 

900 

460 

71 

1,780 

25.0 

3.87 

15 

466 

372 

51 

840 

19.8 

3.08 

4 

60 

52 

3 

42 

14.0 

.80 

10 

704 

149 

17 

309 

30.0 

2.07 

26 

4,850 

2,743 

469 

10,780 

23.0 

3.93 

10 

950 

930 

325 

2,975 

9.0 

3.2 

13 

250 

250 

8 

64 

8.0 

.25 

26 

750 

405 

23 

659 

24.3 

1.62 

12 

145 

145 

19 

221 

11.6 

1.52 

52 

37,294 

28,759 

3,498 

99,144 

35.3 

3.7 

6 

3,500 

3,500 

3,820 

16,920 

6.0 

4.83 

15 

1,152 

800 

134 

938 

7.0 

1.56 

13 

550 

150 

39 

560 

14.3 

3.75 

26 

t" 

133 

21 

775 

36.9 

5.22 

26 

tt 

130 

21 

774 

36.8 

5.95 

314,032 

228,880 

55,487 

1,265,846 

22.8 

5.53 

$        510. 95 

3, 041. 00 

577.00 

172.00 

1,290.94 

5,558.31 

40,331.35 

453,011.25 

1583,141.64 

151,732.00 

91.18 

1,065.77 

381.00 

73, 156. 00 

153,221.00 

491.  82 

641.00 

3, 057. 65 

173. 50 

551.50 

1, 107. 15 

15.70 

912.00 

460.00 

426.  75 

2,572.28 

840.00 

35.00 

582. 08 

7, 717. 10 

4,649.76 

64.10 

593. 10 

221.00 

149,369.60 

8,602.00 

1,343.31 

356.40 

1,085.05 

1,175.00 


$1,625,536.19 


S  10. 43 
34.01 
17.07 

3.01 
10.08 
12.49 
30.72 
36.55 
24.44 
32.92 
18.23 
313. 13 
34.17 
64.03 
51.80 
49.18 
24.65 
12.08 
11.56 
36.76 
35.71 

7.85 
28.50 
20.60 
11.85 
34.82 
16.47 
11.66 
34.24 
18.45 
11.23 

8.00 
25.78 
11.63 
42.73 

3.06 
10.02 

9.14 
51.67 
56.00 


$29.91 


$  2.68 
5.44 
4. 
4. 
4. 
5. 


.61 
,30 
.40 

.48 


:7.54 
8.48 

10.77 
5.11 
.31 
3.34 
5.48 
2.51 

10.19 

11.43 


,63 
,44 
09 
87 
,81 
,39 
,38 
,70 
,54 
59 
,08 
,67 
,90 
,81 
,99 
,25 
1.46 
1.52 
5.58 
2.45 
2.23 
2.37 
8.15 
9.03 


1. 
2. 
3. 
7. 
3. 

3! 
1. 
5. 
5. 
3. 

3*. 
2. 
4. 


$7.22 


♦  (1) 
t  (2) 

t  (3) 
*♦  (4) 

tt  (5) 


Pays  full  benefit  for  14  weeks  and  15  benefits  until  recovery. 
Firm  paid  also  $26,714.45  to  employees  5  years  or  more  in  service.     Firm 
pays  difference  between  salary  and  sickness  benefit  rates  for  10  weeks. 
Data  for  1916.     Figures  for  1917  not  complete. 
Varies  from  13  to  52  weeks  according-  to  length  of  service. 
Numbers  of  employees  not  reported. 


The  rules  governing  the  payment  of  benefits  when  the  disability  is 
the  result  of  immoral  conduct  are  more  lax  in  the  employees'  funds  than 
in  either  of  the  other  two.  Eight  employees'  funds  pay  for  disability 
in  case  of  venereal  disease,  5  for  intemperance  and  9  place  no  limitation 
upon  immoral  conduct.  Among  the  joint  funds  the  corresponding 
figures  are  5,  3  and  3,  and  among  employers'  funds  1  pays  for  disability 
caused  by  intemperance. 

Another  important  aspect  of  the  pa}Tnent  of  benefits  is  the  prompt- 
ness with  which  the  settlement  of  claims  is  made.     From  the  returns 


543 

received  it  appears  that  immediate  payment  of  claims  is  more  common 
in  the  employers'  than  in  the  other  two  types  of  funds,  while  deferred 
payments  are  more  common  among  employees'  funds.  The  figures  for 
those  reporting  on  this  point  show  that  7  of  the  employers'  funds  (all 
reporting),  4-i  of  the  73  joint  funds  reporting,  and  3  of  the  13  em- 
ployees' funds  make  immediate  payments  of  claims,  while  10  employees' 
and  39  joint  funds  make  deferred  payments.  After  the  benefits  have 
been  allowed,  the  majority  of  the  funds  provide  for  weekly  payments. 
Those  that  do  not,  pay  monthly,  or  in  a  lump  sum  after  the  employee 
has  recovered. 

Death  benefits. — In  addition  to  the  foregoing  benefits  it  has  been 
found  that  in  connection  with  a  considerable  number  of  firms  a  death 
benefit  in  some  form  has  been  provided,  such  as  funeral  benefits,  death 
benefits,  group  insurance,  etc.  Benefits  of  this  characcer  nave,  in  some 
instances,  been  provided  by  the  establishment  fund,  in  others,  by  the 
firm  itself.  The  funeral  benefit  is  the  simpliest  form  of  death  benefit 
and  is  provided  by  16  of  the  22  employees'  associations,  60  of  82  joint 
funds,  and  4  of  the  11  employers  funds.  It  seems  to  have  originated 
in  connection  with  employees'  associations  and  probably  antedated  the 
payment  of  sickness  benefits.  The  amounts  paid  are  usually  small,  and 
do  not  ordinarily  exceed  $50  to  $100.  Two  funds  were  found  which 
pay  $200  and  $300  respectively.  It  is  of  interest  to  note  that  this  form 
of  benefit  persists  along  side  of  rather  liberal  insurance  schemes  that  are 
provided  by  some  joint  associations  and  employers'  funds. 

In  only  3  instances  among  the  establishment  funds  studied  are 
funeral  benefits  extended  to  the  employees'  wife  or  other  dependent. 
Three  joint  associations  have  such  a  provision,  but  the  benefits  paid  are 
small,  ranging  from  $30  to  $100  in  case  of  the  death  of  the  wife  and 
from  $20  to  $60  in  case  of  death  of  other  dependents. 

Some  of  the  joint  associations  have  provided  out  of  the  funds  built 
up  by  the  regular  weekly  contributions  a  death  as  well  as  a  sickness 
benefit.  In  some  instances  compensation  for  accidents  and  deaths  from 
accident  is  made  out  of  this  same  fund.  The  payments  may  be  either  a 
fixed  sum,  as  $1,000,  or  graded,  with  amounts  ranging  in  case  of  death 
from  sickness,  from  $200  to  $2,000.  Mne  funds  were  found  that  make 
some  provision. 

In  some  instances  the  burden  of  death  benefit  is  borne  by  the  em- 
ployer. This  is  done  by  providing  group  insurance  through  an  insurance 
company.  This  method  of  providing  against  the  contingency  of  death 
is  of  comparatively  recent  development  among  those  firms  with  establish- 
ment funds.  Thirteen  were  found  that  had  taken  out  group  insurance 
for  their  employees.  From  the  character  of  the  benefits,  it  would  appear 
that -firms  have  taken  out  group  insurance  as  a  means  of  encouraging 
loyalty,  length  of  service  and  efficiency  on  the  part  of  their  employees. 
As  illustrative  of  the  rules  commonly  found  a  $100  benefit  may  after 
one  years'  service  increase  $100  each  year  up  to  $1,500.  The  employees 
in  10  of  the  firms  providing  group  insurance  were  free  to  leave  their  em- 
ployment and  still  retain  the  protection  under  an  individual  policy  pro- 
vided they  individually  assumed  the  rate  of  premium  which  was  re- 
quired at  the  attained  age  of  the  applicant.  This  privilege  was  granted 
to  the  employee  without  medical  examination.     In  the  establishments 


544 

furnishing  group  insurance  either  employees'  or  joint  associations  pay 
sickness  benefits  in  addition  to  the  death  benefits  from  the  insurance.  It 
was  also  fund  that  7  companies  have  provided,  as  a  company  fund,  a 
death  benefit  for  their  employees,  which  ranges  from  $100  to  $2,000. 
There  were  6  employers'  funds,  paying  sickness  benefits,  that  provided  a 
death  benefit  in  case  of  death  from  sickness.  The  amount  of  the  benefit 
varies  with  length  of  service.  A  typical  arrangement  is  the  payment  of 
six  months  salary,  not  to  exceed  $2,000,  when  an  employee  has  been  with 
the  firm  for  5  years  or  more,  and  one  year's  salary,  not  to  exceed  $2,000, 
when  employee  had  served  10  years  or  more. 

Other  benefits  found  among  establishments  where  the  various  types 
of  sickness  and  death  benefit  funds  are  in  existence  are  pensions,  loans, 
profit-sharing,  saving  schemes,  and  general  welfare  work.^*^ 

Contributions. — It  is  in  connection  with  contributions  to  the  fund 
that  we  have  to  look  for  the  basic  differences  among  the  various  types  of 
organization.  Whether  or  not  the  firm  contributes  is  the  test  that 
separates  the  joint  and  employees'  funds.  Although  there  is  one  case 
on  record  where  the  management  of  funds  contributed  entirely  by  the 
employees  is  in  the  hands  of  the  employers,^^  we  found  no  such  instance 
in  the  State  of  Illinois.  In  only  10  cases  where  the  contributions  are 
joint  is  the  management  entirely  in  the  hands  of  the  employers.  In  59 
cases  among  joint  funds  the  only  contribution  of  the  firm  is  the  expense 
attached  to  collecting  dues  from  the  pay-roll  and  in  46  of  these  the 
management  is  conducted  by  the  employees.  In  a  number  of  cases  the 
chief  support  given  to  the  fun^  by  the  firm  has  been  a  contribution  of 
a  definite  sum  when  the  scheme  was  put  into  effect.  This  has  usually 
been  made  to  enable  the  fund  to  pay  benefits  sooner.  But  when  the  firm 
has  promised  to  contribute  a  fixed  sum  annually,  or  an  amount  equal  to 
a  certain  percentage  of  that  provided  by  the  employees,  the  fund  has 
become  typically  a  joint  affair.  This  latter  development  is  usually  ac- 
companied by  joint  administration.  There  are  5  cases  where  the  firm 
contributes  a  fixed  sum  annually,  or  a  definite  amount  per  employee  and 
17  cases  of  a  percentage  of  the  amount  paid  by  the  employees.  The  per- 
centages range  from  10  per  cent  to  100  per  cent  but  the  most  common 
one  is  25  per  cent.  Of  course  in  the  11  employers  funds  the  whole  ex- 
pense is  borne  by  the  firm.  In  17  cases  among  the  joint  funds  the  firm 
guarantees  that  the  benefits  shall  be  paid. 

The  actual  distribution  of  the  costs  between  employers  and  members 
of  the  funds  is  of  interest.  Information  which  will  permit  of  a  com- 
parison of  the  relative  amounts  contributed  by  the  employer  and  em- 
ployee was  received  from  50  of  the  joint  funds.  These  50  establishments 
employed  338,473  workmen,  and  244,528,  or  72.2  per  cent  of  these  were 
members  of  the  funds.  During  the  year  1917  the  sum  of  $4,357,529,  or 
$17.82  per  member  was  paid  into  the  funds.  Of  this  amount  the  em- 
ployers contributed  $498,322,  or  11.4  per  cent,  while  the  employees  con- 
tributed $3,857,207,  or  88.6  per  cent.  In  other  words  the  firms  con- 
tributed $2.03  and  the  members  $15.79  of  the  $17.82— the  total  contri- 
bution ]^er  member.     However,  in  36  of  these  50  funds  the  firms  made 


were 


'"The  respective  number  of  cases  in  whicli  such  provisions  were  present 
16  pensions,  5  loans,  2  profit-sharing,  3  saving  schemes,  and  2  welfare  work. 

^^  Monthly  Review  of  U.  S.  Dept.  of  Labor,  Bureau  of  Labor  Statistics,  August, 
1917,  p.  20. 


545 

no  money  contribution.  In  many  of  these  cases  tlie  only  contribution 
made  was  the  "checking  off"  of  dues  from  the  wages  of  the  members, 
thus  reducing  the  cost  of  collection.  In  the  remaining  14  funds  the  firms 
made  a  money  contribution  and  the  relative  amounts  contributed  have 
been  separately  studied.^-  There  were  242,585  emplo^'ees  and  167,431 
members  in  these  14  establishments,  or  in  other  words  71.6  per  cent  of 
workmen  and  68.4  per  cent  of  the  members  of  the  50  funds  under  con- 
sideration. During  1917  there  was  paid  into  these  14  funds — $3,895,- 
917,  or  a  total  of  $23.26  per  member.  The  firms  contributed  $498,322, 
or  12.8  per  cent  while  the  members  contributed  $3,397,595,  or  87.2  per 
cent.  In  other  words  of  the  total  amount  contributed  per  membed — 
$23.26— the  firm  paid  $2.97  and  the  members  $20.29.  To  the  contri- 
butions of  tlje  firm  should  be  added  the  cost  of  collection  of  dues  and  the 
contributions  toward  the  administration  of  the  funds  concerning  which 
no  data  were  received. 

In  only  9  cases  does  the  firm  require  a  release  clause. as  a  condition 
of  making  its  contribution.  This  undoubtedly  is  a  persistence  of  the 
arrangement  so  prevalent  before  workmen's  compensation  came  into 
effeot.  Of  course  such  a  requirement  is  not  applicable  where  the  com- 
pensation is  for  sickness  and  non-industrial  accidents  which  do  not  give 
the  employee  a  right  of  action  for  damages.  Even  where  there  may  be 
an  attempt  to  handle  the  compensation  of  industrial  accidents  by  such 
an  arrangement  it  will  not  relieve  the  firm  from  damages  unless  the  em- 
ployee definitely  accepts  the  benefits  as  a  settlement. 

The  sources  of  income  of  establishment  funds  are  the  regular  con- 
tributions from  members  and  payment  made  by  the  firms — the  character 
and  amounts  of  which  depend  upon  the  type  of  fund.  The  contributions 
of  the  employees  consist  of  dues,  special  assessments,  and  such  supple- 
mentary sums  as  fines  for  breaking  rules,  fees  for  initiation  and  rein- 
statement, interest  on  loans  and  returns  from  special  occasions  held  for 
the  benefit  of  the  funds.  The  dues  are  in  some  instances  a  fixed  sum 
per  week,  the  amounts  ranging  from  2%  to  19  cents  per  week ;  in  other 
instances  the  dues  are  graded,  the  amounts  ranging  from  87%  cents  to 
$1.25  per  week.  There  are  40  associations  that  charge  graded  rates. 
A  number  of  considerations  affect  the  variation  of  these  rates.  The 
rates  may  vary  in  accordance  with  wages  earned,  or  with  the  degree  of 
hazard  of  one  group  of  employees  as  compared  with  that  of  another. 
For  example,  in  the  railroad  business  those  employees  engaged  in  oper- 
ating trains  pay  $1.25  per  week  in  the  highest  class  while  those  in  the 
same  wage  class  in  other  less  hazardous  lines  of  work  pay  93%  cents. 
Then,  the  dues  may  vary  on  account  of  the  kinds  of  benefits  furnished 
or  the  length  of  time  benefits  are  paid.  The  collection  of  dues  in  em- 
ployees' funds  is  in  every  instance  by  the  organization  itself,  while  among 
joint  funds  the  dues  are  collected  from  pay-roll  except  in  five  instances. 

Special  assessments  are  an  important  source  of  income.  In  fact, 
in  some  of  the  funds  it  is  the  only  form  of  income.  In  48  cases  special 
assessments  in  addition  to  dues  are  found.  In  39  cases  the  assessment 
is  used  to  provide  sickness  benefits,  and  in  22  to  provide  death  benefits. 

"These  14  funds  include  3  railroads,  but  the  relative  proportion  of  firms  con- 
tributions is  slightly  less  for  these  than  the  average  of  all  the  14  funds. 

—35  HI 


546 


Thirteen  associations  use  assessments  for  both  sickness  and  death  bene- 
fits. Thirty  of  the  funds  limit  the  amount  of  the  assessments  and  these 
limits  vary  from  10  cents  to  $4.  Some  associations  use  assessments  as 
a  means  of  keeping  a  balance  on  hand  that  is  regarded  as  adequate  to 
meet  the  demands  upon  it. 

Another  form  of  sickness  benefit  found  in  establishments  is  the 
hospital  association,  which  provides  treatment  at  a  hospital  instead  of 
money  benefits.  Three  such  associations  were  located.  They  operate 
along  the  same  general  lines  as  the  employers'  and  joint  funds.  The 
payment  of  a  stipulated  premium  per  month  entitles  a  member  to  medi- 
cal and  surgical  treatment  for  sickness  and  accident  for  a  definite  period 
of  time.  Extension  of  such  treatment  beyond  the  time  specified  can  be 
had  only  at  the  expense  of  the  employee  unless  special  exception  has  been 
made  by  the  board  of  trustees.  Employees  were  represented  on  this 
board  in  two  of  the  three  cases  found. 

Physical  care. — Within  the  last  few  years  an  increasing  appreciation 
of  the  importance  of  proper  medical  care  of  employees  has  been  develop- 
ing. In  fact,  the  extent  to  which  measures  have  already  been  taken  in 
this  direction  is  sufficient  justification  for  classifying  such  efforts  as  a 
part  of  the  benefits  which  accompany  pecuniary  aid.  Naturally  the  first 
use  of  medical  care  accompanied  the  effort  to  relieve  suffering  in  acci- 
dent cases.  But  the  practical  results  obtained  in  the  reduction  of  ex- 
pense to  the  firm  and  in  the  rapid  recovery  of  the  employee  demon- 
strated the  importance  of  extending  such  service  to  the  care  and  pre- 
vention of  sickness.  Moreover,  there  is  definite  testimony  to  the  bene- 
ficial effects  that  it  has  had  on  the  general  efficiency  of  the  employee  and 
to  the  encouragement  it  has  given  to  more  cordial  relations  between  the 
employer  and  his  working  force.^^ 

It  is  very  encouraging  to  find  that  medical  care  is  taking  on  a  larger 
asf)ect  than  the  mere  relief  of  distress.  In  fact,  the  same  principles 
which  are  applied  in  conection  with  the  relief  and  prevention  of  accidents 
are  quite  as  effective  in  dealing  with  the  burden  of  sickness.  Those 
who  are  in  the  vanguard  in  this  movement  are  convinced  that  the  im- 
})ortance  of  hastening  recovery  of  the  disabled  is  no  greater  (if  as  great) 
than  tlie  prevention  of  recurrence.  The  cooperation  of  the  physician 
and  the  safety  engineer  can  do  more  than  to  locate  the  blame  of  the  em- 
ployee or  employer  for  accident  or  sickness.  Not  onlv  can  they  bring 
a  better  regime  of  safety  and  sanitation  in  the  industrial  plant,  but  thev 
can  reach  out  mto  the  home  of  the  employee  in  a  way  that  lessens  their 
problems  at  the.  plant.  When  a  firm  is  able'  to  announce  definitely 
tliat  it  has  reduced  through  such  measures  the  amount  of  time  lost  on 
account  of  sickness  by  40  per  cent  the  question  has  been  taken  out  of 
the  realm  of  theory  and  reduced  to  the  level  of  practice.^* 

The  use  of  medical  examination  is  taking  on  a  larger  function  than 
the  mere  discovery  of  disease  and  unfitness  for  employment.  Those  who 
appreciate  Its  possibilities  are  encouraging  the  employee  to  report  at  once 
to  the  doctor  when  he  is  feeling  sick.  This  is  proving  as  important  an 
the  requirement  of  immodin^o  attention  to  scratches  and  slight  acci- 

pp.  439^*4^9. ^^''^'  '''"^*"'  ''""'■'"''  ''^  ^"^°^  Statistics,  Monthly  Review,  March,  1917, 
-}TontMy  Review  of  U.  8.  Bureau  of  Labor  Statisti<.s,  March,  1917,  p.  446. 


547 

dents  which  may  cause  infection.  Furthermore,  frequent  reexamination 
not  only  supplements  efforts  to  attain  the  maximum  of  efficiency  of  each 
employee,  but  it  also  is  a  great  aid  in  the  prevention  of  contagious, 
chronic  diseases,  and  permanent  disability.  Those  who  are  making 
the  wisest  use  of  medical  examination  testify  not  only  to  the  small  per- 
centage of  rejection  of  applicants  for  emplo}Tnent,^^  but  appreciate 
the  use  to  which  it  can  be  put  in  properly  placing  an  employee  at  the 
time  of  his  induction  into  the  business  and  in  re-placing  him  in  his 
progress  from  one  department  to  another. 

Information  concerning  the  amount  and  character  of  medical  treat- 
ment furnished  employees  was  received  from  115  firms  where  establish- 
ment funds  were  located.  In  only  43  instances  was  claim  made  that 
medical  treatment  was  provided.  This  treatment  is,  in  some  instances, 
furnished  by  the  fund  and  in  others  by  the  firm.  In  some  cases  the 
-expenses  insurred  are  shared  between  the  firm  and  the  association,  the 
firm  caring  for  the  disabilities  arising  during  the  course  of  employment, 
while  the  fund  provides  for  those  arising  "off  duty."  In  17  of  the  43 
funds  provision  is  made  by  the  fund  for  medical  treatment  in  some  form. 
In  4  of  these  17  cases  the  firm  either  Joins  in  the  expense  of  this  treat- 
ment or  assumes  the  expense  of  a  certain  part  of  it,  as  indicated  above. 

The  treatment  provided  by  the  funds  is  in  the  main  confined  to 
the  members,  but  in  one  case  arrangements  are  made  whereby  members 
of  the  family  receive  medical  attention  at  reduced  charges.  In  16  of 
the  17  funds  providing  medical  treatment,  one  or  more  physicians  are 
retained  either  upon  salary  (8  cases)  or  by  definite  agreement  in  respect 
to  charges  (8  cases).  In  1  case  there  is  no  arrangement  with  physicians 
but  treatment  is  provided  when  needed.  In  11  cases  this  treatment  is 
extended  to  the  home  of  the  disabled  member,  in  3  cases  it  is  confined 
chiefly  or  wholly  *to  the  establishment,  and  in  3  cases  information  on 
this  point  was  not  reported.  In  13  cases  surgical  care  is  provided,  but 
in  some  of  these  cases  this  care  amounts  to  little  more  than  first  aid, 
or  is  provided  in  special  cases,  while  in  one  case  there  is  no  limit  on  care 
given.  In  only  10  cases  is  there  any  claim  to  furnishing  hospital  care, 
and  this  usually  by  order  of  the  association  physician  or  by  vote  of 
directors  of  the  fund.  In  one  case  provision  for  3  weeks  hospital  care 
is  made;  in  another  the  sick  benefits  can  be  turned  to  payment  for 
hospital  care,  while  in  one  the  care  is  confined  to  tuberculosis  cases. 

In  a  few  instances  provision  is  made  by  the  fund  for  nursing  and 
for  medical  supplies.  However,  these  services  are  more  commonly 
furnished  by  the  firm  and  will  be  treated  in  that  connection. 

In  addition  to  the  medical  treatment  furnished  by  the  establishment 
funds  it  was  found  that  a  considerable  number  of  the  firms  make  pro- 
vision for  treating  their  employees,  especially  in  cases  of  emergency. 
This  treatment  is  in  some  instances  supplementary  to  treatment  furn- 
ished by  the  fund  and  may  have  been  undertaken  in  connection  with 
the  physical  examination  of  applicants  for  employment.  Of  the  115 
funds  reporting,  72  made  no  claim  of  furnishing  physical  care.  Of  the 
43  claiming  to  provide  some  physical  care,  such  care  amounts  to  little 

"Ibid.,  p.  441. 


r548 


more  than  advice  and  first  aid.  Twenty-three  maintain  on  salan^  one 
or  more  physicians.  In  4  additional  cases  the  firm  joins  with  the  fund 
either  in  sharing  the  expense  of  the  physician,  or  in  furnishing  part  of 
the  medical  treatment.  In  three  other  cases  the  firm  makes  provision 
for  treatment  when  it  is  needed.  In  the  remaining  13  instances  the 
nature  of  the  care  was  not  reported. 

In  9  of  these  30  cases  this  treatment  is  confined  to  the  establish- 
ment except  in  cases  of  emergencies.  In  15  of  the  cases  the  information 
indicates  that  the  care  is  extended  to  the  home  of  the  employee.  In  a 
majority  of  these  instances  this  care  is,  however,  in  connection  with 
emergency  cases  and  does  not  extend  much  beyond  general  medical 
advice  and  first  aid. 

The  same  general  statement  holds  concerning  hospital  care,  nursing, 
medical  supplies  and  dental  care,  furnished  by  the  firm.  It  was  found 
to  be  quite  common  for  the  firm  to  furnish  hospital  care  in  accident 
cases,  but  this  is  not  customary  in  sickness  cases.  In  21  cases  one  or 
more  nurses  are  retained  to  assist  in  medical  treatment.  Usually  this 
service  is  supported  wholly  by  the  firm  although  in  one  instance  the  fund 
shared  the  expense.  In  some  instances  nursing  is  confined  to  first  aid 
and  emergency  cases  in  the  establishment,  while  in  others  the  nurses 
visit  the  home  of  the  disabled  employee.  In  one  case  where  a  consider- 
able number  of  female  employees  were  at  work,  provision  is  made  for  3 
nurses  at  the  place  of  work  and  in  addition  11  visiting  nurses  are  em- 
ployed to  visit  the  homes  of  the  employees.  In  30  cases  medical  sup- 
plies are  furnished  either  by  the  firm  or  the  establishment  fund,  but 
most  commonly  by  the  former.  These  supplies  vary  from  first  aid 
supplies  to  the  filling  of  prescriptions  free  of  charge.  Finally,  in  8 
cases  it  was  claimed  that  some  dental  care  is  furnished  but  with  two  ex- 
ceptions this  care  is  in  emergency  cases  only.  Tw^  cases  were  found 
where  dental  work  is  furnished  employees  at  cost  and  in  one  of  these 
the  cost  is  confined  to  cost  of  materials  as  the  dentist  is  retained  on 
salary  by  the  firm. 

In  addition  to  the  medical  treatment  described  above  one  benefit 
association  has  given  special  attention  to  tuberculous  cases.  Provision 
is  made  for  care  at  a  sanitorium.  The  amount  and  results  of  this  treat- 
ment for  the  two  years  1915  and  1916  compared  with  cases  not  so 
treated  are  shown  in  the  following  table. 

There  was  also  found  an  association  of  employers  that  maintains 
a  sanatorium  in  New  Mexico,  primarily  for  the  care  of  tuberculous 
cases  among  employees  and  members  of  their  families.  Forty-one  of 
the  forty-four  members  of  the  association  were  located  in  Chicago. 
rreatment  is  furnished  to  employees  at  cost  and  in  some  cases  where 
the  employee  cannot  afford  it,  the  expense  is  borne  by  the  firm. 

It  would  appear,  therefore,  that  many  establishments  do  not  do  more 
m  the  way  of  medical  treatment  than  to  give  advice  and  temporary  re- 
lief for  sickness  at  the  plant.  When  further  treatment  is  needed  in  the 
home  the  employee  is  advised  to  call  his  private  physician.  Many  con- 
cerns pursue  this  policy  to  avoid  opposition  from  the  medical  profession. 
rhey  may,  however,  follow  up  a  case  to  see  that  proper  attention  is  given. 


549 


TWO  YEARS  ESTABLISHMENT  EXPERIENCE  WITH  TUBERCULOSIS. 


Years. 


1915 


1916 


With  sanatorium  treatment — 

Died  at  sanitorium 

Left  sanatorium  and  died 

Lump  sum  settlement 

Left  sanatorium  with  52  weeks  benefits. 

Recovered  and  returned  to  work 

Still  disabled  at  sanatorium 

Left  sanatorium  but  still  disabled 


Total 

Without  sanatorium  treatment — 

Died 

Lump  sum  settlement 

Recovered  and  returned  to  work. 

Drew  52  weeks  benefits 

Still  disabled 


Total. 


22 


5 

3 

4 
1 

1 

5 

1 

14 

9 

20 

29 

7 

7 

56 

50 

1 

11 

3 
5 

9 

1 

13 

10 

31 


In  only  two  cases  were  any  data  received  as  to  how  long  the  above 
services  were  extended  without  charge  to  the  employee.  Where  replies 
were  given  they  were  in  general  terms  such  as  "depends  on  extent  of 
injury"  or  "as  required."  The  duration  of  such  .services  without  extra 
charge  is  of  great  significance,  if  benefits  of  this  character  are  to  be  paid 
out  of  a  fund  established  by  premiums. 

Conclusion. — From  the  foregoing  study  of  the  methods  of  re- 
lieving the  burden  of  sickness,  certain  conclusions  can  be  dra^vTi.  In 
the  first  place,  the  growth  and  elaboration  of  the  provisions  for  relief  of 
sickness  through  establishment  funds  is  convincing  proof  of  the  felt  need 
for  such  measures.  It  is  also  clear  that  this  method  of  caring  for  sick- 
ness, developed  on  a  voluntary  basis,  has  after  all  been  provided  in  only 
a  relatively  small  number  of  plants  and  only  for  a  relatively  small  pro- 
portion of  the  wage-earners  of  the  State.  A  third  feature  is  the  great 
diversity  of  provisions.  Some  funds  are  well  managed  and  have  liberal 
benefits,  others  are  poorly  managed  and  the  benefits  are  inadequate. 


550 


SPECIAL  REPORT  XII.     TRADE  UNION  BENEFIT  SYSTEMS. 

.     (By  A.  E.  Suff&rn,  Ph.  D.) 


JiLtruduciiuii. 

The  Health  Insurance  Commission  as  a  part  of  its  investigation  of 
voluntary  mutual  insurance  undertook  a  survey  of  the  provisions  found 
among  national,  international  and  local  trade  unions.  Similar  surveys 
have  been  made  by  other  states  and  by  the  Federal  Government.^  Those 
by  the  states  have  been  for  the  purpose  of  determining  the  extent  of 
such  arrangements  in  particular  jurisdictions  and  those  by  the  Federal 
Government  to  obtain  information  that  would  be  representative  of  the 
situation  in  the  country  at  large. 

Such  provisions  were  first  made  by  local  unions  and  were  grad- 
ually incorporated  into  the  trade  union  program  as  unions  in  creased  in 
size  and  became  stable  organizations.  In  fact  it  was  early  appreciated 
that  mutual  insurance  would  give  a  much-needed  protection  and  en- 
courage cohesion  and  solidarity  on  the  part  of  the  trade  union  mem- 
bership. The  earliest  known  attempt  to  make  use  of  benefit  funds  is 
found  among  typographical  unions  which  established  death  benefits  in 
1815.2 

It  was  not  until  after  the  Civil  War  that  unions  attained  sufficient 
control  to  establish  benefit  features  national  in  scope.  The  national 
union  to  pioneer  in  this  matter  was  the  Brotherhood  of  Locomotive 
Engineers,  which  established  death  and  permanent  disability  benefits 
in  1867.*  With  the  rapid  growth  of  national  unions  in  the  eighties 
and  nineties  many  of  them  instituted  the  death  benefit  at  the  time  of 
their  organization.  This  is  the  form  of  benefit  most  frequently  pro- 
vided, but  during  the  last  thirty  years  there  has  been  a  gradual  widen- 
ing of  the  range  of  benefits  so  as  to  cover  accident,  sickness,  permanent 
disability,  superannuation,  death  of  wife  or  other  dependent,  and  un- 
employment. The  local  unions  have  followed  much  the  same  course  of 
development  during  the  last  thirty  years. 

Of  the  more  than  110  important  national  and  international  unions 
in  the  United  States  94:  have  reported  to  the  Commission  their  mem- 
bership in  the  State  of  Illinois.  All  told,  these  94  have  2,339  local 
unions  in  the  State  with  a  membership  of  387,285.  To  these  should 
be  added  tlie  number  and  membership  of  locals  affiliated  with  national 
and  international  organizations  not  reporting  to  the  Commission  and  the 
number  and  membership  of  locals  without  such  affiliation.     From  the 

Review'^AuLl^T^^'^^ntlhi'^T^^  5^^'"'"^  ^^  ^-  -^^  ^°*^-  °/  ^"^^^^  1909'  and  Monthly 

«  ri«ii^«  *i'Jw  V-  ®^  \^o  ^-  ^-  Bureau  of  Labor  Statistics. 

•Ib?d     S    244   ^ilt^^'li^^^V  °^  Commissioner  of  Labor,  p.  200. 
Unions  ••>(>fcM;^««fc!«;    n^L^l^P^^I:   "Beneficiary  Features   of  American   Trade 
Series  XXVI         ^^^^^""^    University    Studies   in   Historical    and    Political    Science, 


551 

information  at  hand,  it  is  estimated  that  the  total  number  of  locals  in 
the  State  is  somewhat  more  than  2,500,  with  a  membership  of  410,000 
or  more. 

Eighteen  national  and  international  organizations  have  made  syste- 
matic provision  for  the  payment  of  sick  benefits.  Fifteen  of  these  are 
lepresented  in  Illinois  with  336  locals  and  33,208  members.  Benefits 
are  paid  in  sums  varying  from  $3  to  $12  per  week,  usually  with  a 
maximum  of  12  or  13  weeks  in  the  year,  for  disabilities  lasting  more 
than  7  or  14  days.  Some  of  the  locals  of  at  least  five  of  these  fifteen 
organizations  provide  additional  sick  benefits  ranging  from  $4  to  $10 
per  week.  These  five  nationals  and  internationals  have  a  total  of  183 
locals  with  a  membership  of  17,097  in  the  State. 

There  are  perhaps  380,000  unionists  in  some  2,200  locals  not  affili- 
ated with  those  nationals  or  internationals  which  provide  sick  benefits.* 
By  questionaires  and  by  correspondence  information  was  secured-  from 
898  of  these  mth  194,524  members.  Of  these,  223  with  70,443  members 
were  found  to  have  made  provision  for  the  payment  of  sick  benefits 
ranging  from  $4  to  $10  per  week.  Of  this  membership  there  were 
58,391  who  had  met  the  various  requirements  set  up  by  the  unions,  and 
were  eligible  for  benefits.  Our  experience  in  securing  information  from 
these  unions  has  led  to  the  conclusion  that  the  returns  are  fairly  repre- 
sentative of  the  entire  number  of  locals  not  affiliated  with  general  organi- 
zations providing  sick  benefits.  If  such  is  the  case,  there  would  be  some 
136,000  unionists  in  the  State  with  membership  in  local  unions  making 
provision  for  benefits  paid  out  of  local  funds.  In  this  way  an  estimate 
is  arrived  at  that  41  per  cent  of  the  union  men  and  women  of  the  State 
are  connected  with  unions  maintaining  national  or  local  systems  of  sick 
benefits.  It  would  appear  that  more  than  four-fifths  of  these  are  "bene- 
ficial" members.  Hence  it  mav  be  said  that  about  a  third  of  the  mem- 
bers  of  labor  organizations  in  the  State  are  paid  sick  benefits  in  accord- 
ance with  the  rules  under  which  the  funds  are  administered. 

Many  national  and  international  unions  provide  funeral  benefits 
or  death  benefits  amounting  to  life  insurance.  It  was  found  that  64 
national  organizations,  with  1,591  locals  and  a  combined  membership 
of  229,046  in  Illinois,  provide  funeral  benefits  and  life  insurance  rang- 
ing from  $20  to  $4,500.  In  connection  with  death  benefits  as  well  as 
sickness  benefits,  many  local  unions  also  pay  something  in  addition  to 
the  amount  provided  by  the  national  organization.  This  may  range 
from  $20  to  $500.  The  request  for  information  brought  a  response 
from  771  of  the  1,591  locals  among  national  organizations  paying  death 
benefits.  Of  these  locals,  83  with  a  membership  of  28,146  indicated  that 
they  paid  additional  death  benefits  varying  as  stated  above. 

Among  the  important  national  organizations  not  providing  death 
benefits  is  the  United  Mine  Workers  of  America.  In  this  case  the  State 
organization   (District  XII)   pays  a  death  benefit  of  $250.     There  arc 

*The  Commission  has  reports  on  1,923  such  locals  with  a  combined  member- 
ship of  337,704.  From  available  information  it  seems  that  there  are  perhaps  be- 
tween 250  and  300  locals  affiliated  with  national  organizations  not  reported  or 
without  affiliation  with  any  superior  body.  Hence  the  above  estimates  which  can  be 
regarded  as  only  approximately  correct. 


552 

305  miners'  locals  with  a  membership  of  90,000  in  the  State.  Of  these 
127  locals  with  a  membership  of  41,697  reported.  In  this  organization 
many  locals  also  pay  additional  death  benefits  ranging  from  $25  to  $500 
Of  the  127  locals  reporting  it  was  found  that  90  with  a  membership  of 
31,575  make  this  additional  provision. 

Beturns  were  also  received  from  62  locals  with  a  membership  of 
24,396  paying  death  benefits  in  sums  ranging  from  $50  to  $400.  The 
national  organizations  of  which  these  locals  were  members  paid  no  death 
benefits.  Combining  data  at  hand  it  may  be  estimated  that  approxi- 
mately 7  in  8  of  the  members  of  unions  in  Illinois  belong  to  organizations 
paying  death  benefits  or  providing  life  insurance  out  of  the  local,  state, 
or  national  funds. 

The  degree  of  protection  in  union  funds  can  only  be  appreciated  by 
a  detailed  study  of  the  conditions  under  which  a  member  may  gain 
entrance  to  the  fund,  the  provisions  relating  to  the  waiting  period,  the 
duration  of  benefits,  the  amount  of  benefit  per  w^eek,  and  the  causes 
which  may  deprive  him  of  benefits.  The  adequacy  of  such  benefits  is 
further  affected  by  the  extent  of  medical  care  which  accompanies  them. 
The  method  of  administration  of  claims  and  the  administration  of  the 
fund  may  be  greatly  affected  by  trade  union  policy  and  in  the  last ' 
analysis  determine  the  degree  of  security  which  the  member  may  have 
of  receiving  protection.  These  matters  will  be  considered  in  the  re- 
mainder of  this  report. 

Membership. 

The  conditions  under  which  membership  may  be  obtained  in  trade 
union  funds  affect  vitally  the  value  of  this  form  of  insurance.  In  most 
of  the  national  unions  membership  in  the  benefit  fund  is  compulsory 
if  the  applicant  can  pass  a  physical  examination.^  In  many  others 
membership  merely  entitles  one  to  take  advantage  of  the  protection  if 
he  is  free  from  chronic  disease  and  if  he  meets  the  requirements  of  age 
and  length  of  affiliation.  Among  151  local  unions^  reporting  that  they 
provide  sickness  benefits,  74  per  cent  make  membership  compulsory, 
but  only  23  per  cent  of  these  require  a  medical  examination.  The 
amount  of  care  in  the  selection  of  risks  was  found  to  be  somewhat  greater 
among  locals  permitting  voluntary  membership  for  thirty-seven  per  cent 
of  these  locals  require  a  medical  examination. 

Many  of  the  national  unions  have  set  up  age  limits  as  a  condition 
of  membership,  in  the  benefit  funds  the  lower  limits^which  vary 
from  18  to  21  and  the  upper  limits  from  40  to  60.  Practically  the  same 
variation  exists  among  local  unions  with  the  emphasis  upon  an  upper 
limit.  Twenty-four  per  cent  of  the  locals  reporting  have  such  a  regula- 
tion. This  requirement  is  often  softened  by  admitting  the  member  to 
trade  privileges  and  partial  benefits. 

Another  qualifying  factor  in  regard  to  membership  is  frequently 
found  in  connection  with  a  minimum  time  of  affiliation  before  the  mem- 

1 2if ***i^'^^^^f  ^*^!^^^^  Report,  V.  S.  Commissioner  of  Labor,  p.  26. 
^    .   .  .*   petaUed    reference    to    features    of   membership,    benefits,    revenues,    and 
f  u  i"i5^'',  ci°r  °\  '°P^'  unions  are  based  upon  more  comprehensive  information  furn- 
ished by  151  locals  from  various  unions  in  response  to  a  second  questionnaire.     This 
waa  sent  to  locals  known  to  have  sickness  benefit  funds 


553 

ber  is  permitted  to  receive  benefits  from  the  fund.  Among  both  na- 
tional and  local  unions  this  requirement  may  vary  from  a  few  weeks 
to  one  year.  The  most  usual  periods  are  3  and  6  months.  A  further 
limitation  on  membership  is  placed  upon  those  suffering  from  chronic 
disease.  Thirty-seven  per  cent  of  the  locals  reporting  include  this  regu- 
lation. That  these  exclusions  are  effective  is  shown  by  the  local  records 
covering  1,917  men.  There  were  157  members  who  were  excluded  be- 
cause of  the  age  limit,  573  because  of  too  brief  affiliation  and  9  because 
of  chronic  disease,  or  a  total  of  739  among  the  grand  total  of  1,917. 

Temporary  Disability  Benefits. 

The  two  forms  of  temporary  disability  benefits  which  trade  union 
funds  provide  are  for  sickness  and  accident.  The  rate  of  benefit  is 
usually  the  same  for  both,  but  in  many  instances  there  is  either  no  wait- 
ing period  for  accidents  or  the  period  is  less  than  for  sickness.  Among 
the  national  unions  providing  temporary  disability  benefits  three-fifths 
have  a  waiting  period  of  seven  days,  the  others  fourteen  days.  It  has 
been  shown  by  a  recent  federal  investigation^  of  national  union  funds 
that  the  length  of  the  waiting  period  has  a  very  decided  effect  upon  the 
extent  of  the  claims  upon  the  funds.  A  waiting  period  of  fourteen  days 
as  against  one  of  seven  decreases  the  claim  for  disability  by  one-third. 
Among  the  local  trade  unions  in  the  State  reporting  18  per  cent  had  no 
waiting  period,  2  per  cent  had  a  period  of  less  than  seven  days.  For 
53  per  cent  the  period  was  seven  days,  for  14  per  cent  a  period  of  four- 
teen days.  The  remaining  10  per  cent  was  distributed  among  local 
unions  having  a  waiting  period  of  between  seven  and  fourteen  days,  and 
one  with  a  period  of  21  days. 

The  period  during  which  benefits  may  be  claimed  is  another  im- 
portant factor  affecting  the  degree  of  protection.  Among  national  union 
funds^  it  varies  from  six  weeks  to  two  vears,  "with  three  months  as  the 
most  frequent  period.  Practically  the  same  variation  is  found  among 
local  union  funds  except  that  the  range  falls  below  six  weeks  in  a  few 
cases  and  that  provision  is  frequently  made  for  extension  of  benefits  by 
donations.  One  union  pays  $7  a  week  indefinitely.  Others  pay  the  full 
rate  for  a  specified  period  and  then  reduce  the  rates  for  further  periods. 

Among  national  union  funds  the  cash  benefit  per  week  varies  from 
$3  to  $12.  The  most  frequent  rate  is  $5  per  week.  Much  the  same 
may  be  said  of  local  union  funds.  Here,  however,  in  a  few  cases,  the 
practice  has  been  established  of  paying  graded  rates,  the  minima  vary- 
ing from  $3  to  $7  and  the  maxima  from  $4  to  $10.  Not  only  are  these 
money  benefits  inadequate  to  meet  the  needs  of  a  family  in  time  of 
sickness  but  there  is  almost  a  complete  absence  of  medical  and  hospital 
care  among  national  and  local  union  funds.  Four  local  unions  report 
that  the  attending  physician  is  paid  by  the  union.  A  few  others  state 
that  hospital  care  and  surgical  treatment  is  furnished  in  case  of  need. 

Practically  all  of  the  national  unions  provide  for  forfeiture  of 
benefits  in  case  temporary  disability  is  caused  by  intemperance  and  im- 
moral conduct.     Seventy-six  per  cent  of  the  local  unions  reporting  put 

''Monthly  Review  of  United  States  Bureau  of  Labor  Statistics,  August  17,  1917, 
p.  29. 

8  Ibid.,  p.  29. 


554 


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556 

such  a  limitation  upon  their  members  while  62  per  cent  set  up  restrictions 
on  conduct  while  the  member  is  receiving  benefits.  Prohibitions  against 
the  use  of  liquor,  engaging  in  any  work,  and  disobeying  doctors'  in- 
structions are  frequently  found  among  these  restrictions. 

In  order  that  the  variation  and  the  nature  of  the  provision  made 
by  different  unions  may  be  more  fully  comprehended  it  will  be  well  to 
present  certain  features  in  tabular  form  from  the  data  furnished  by  44 
locals  for  the  year  1917.^  The  schedules  from  these  showed  the  number 
of  members  in  the  union,  the  members  in  the  fund,  the  number  of  mem- 
bers receiving  benefits  and  the  amount  spent  for  temporary  disability. 
In  connection  with  these  data  it  is  important  to  consider  the  length  of 
the  waiting  period,  the  duration  of  payment,  and  the  rate  of  benefit 
per  week.  All  of  these  are  factors  affecting  the  adequacy  and  cost  of 
protection. 

Out  of  a  reported  membership  of  11,228  there  were  10,148  or  90  per 
cent  in  the  funds.^^  Of  those  in  the  fund  1,735,  or  16  per  cent,  received 
benefits  for  temporary  disability.  The  payments  aggregated  $40,002.41, 
or  an  average  of  $23.05  per  case.  This  was  approximately  $1  per  day 
per  disabled  member.  This  amount  of  protection  was  furnished  at  an 
average  yearly  cost  of  $3.76  per  member. 

The  members  who  received  benefits  were  disabled  for  a  total  of 
34,867  days,  or  an  average  of  23.8  days  each.  This  average  would  not 
be  changed  greatly  by  including  the  disability  of  270  members  of  three 
funds  which  failed  to  report  on  this  matter.  The  report  of  42,942  days 
as  the  total  disability  or  an  average  of  4.72  days  for  the  entire  member- 
.  ship,  does  not  show  the  full  number  of  days  of  disability.  In  the  first 
place,  seven  funds  did  not  report.  Furthermore,  all  of  the  funds  ex- 
cept two  have  waiting  periods  varying  from  3  to  21  days.  In  most 
funds  no  attempt  is  made  to  keep  a  record  of  the  disability  of  members 
who  are  not  sick  longer  than  the  waiting  period.  The  record  of  the  166 
members  in  the  funds  without  a  waiting  period  is  practically  valueless 
as  an  indication  of  sickness  experience. 

Too  much  stress  should  not  be  placed  upon  the  use  of  averages  as 
characterizing  a  particular  fund  or  all  the  funds.  The  variation  in  the 
rate  of  benefit,  the  length  of  waiting  period,  and  the  duration  of  benefit 
are  all  modifying  factors. 

Permanent  Disability  Benefits. 

The  provision  for  permanent  disability  benefits  supplementary  to 
temporary  disability  is  made  by  19  national  unions."  The  loss  of  a 
hand,  foot  or  eye  and  paralysis  are  deemed  sufficient  basis  for  claim  to 
this  benefit.  The  amount  paid  for  such  disability  is  usually  the  same  as 
that  for  death  benefits.  In  some  unions  the  receipt  of  permanent  dis- 
ability  benefit  deprives  the  member  of  any  claim  to  a  death  benefit.     In 

•flee  Table  I. 

»*Pund  Number  117  Is  a  report  of  a  Printers'  Mutual  Benefit  Association  which 
Includes  members  of  many  shops.  The  membership  of  486  of  this  association  brings 
the  total  of  protected  members  up  to  10,634 

on  nn^^*^i^;^'**r^jl^'I.H?i  ^^KVi  Vu  ^^  Comrnissioner  of  Labor,  p.  31.     The  tables 
abinty  indicate  that  there  are  22  unions  paying  for  permanent  dis- 


557 

others,  he  is  entitled  to  reduced  death  benefits.  Among  some  unions 
the  amount  paid  varies  with  the  number  of  years  the  member  has  been 
in  good  standing.  For  example,  the  United  Brotherhood  of  Carpenters 
and  Joiners  pays  from  $50  to  $400  in  accordance  with  a  variation  of 
one  to  five  years  in  membership.  In  other  unions  variations  in  amount 
of  benefit  is  based  on  a  classification  both  of  length  of  membership  and 
age.  This  is  illustrated  by  the  following  scale  established  by  the 
Amalgamated  Association  of  Street  and  Electric  Railway  Employees. 


Members 

prior  to 

Jan.  1, 

1918. 


Under 
45. 


45-50 


50-«0 


Over   60. 


2d  year . 
3d  year . 
4th  year 
5th  year 
6th  year 
7th  year 
8th  year 
After... 


$100 

$100 

$100 

$  50 

150 

150 

150 

100 

250 

250 

250 

150 

400 

400 

350 

200 

500 

500 

400 

250 

600 

600 

450 

275 

700 

700 

500 

300 

800 

800 

550 

300 

$  50 

75 
100 
100 
100 
100 
100 
100 


Again  such  benefits  may  vary  in  amounts  according  to  a  classi- 
fication by  age  and  the  amount  of  monthly  assessments  paid  into  the 
fund.  The  plan  is  illustrated  by  the  arrangement  established  by  the 
Locomotive  Firemen  and  Enginemen: 


Principal  sum.* 


Weekly 
indemnity. 


Monthly 
assess- 
ments. 


Annual 
cost. 


$1,000 
1,000 
1,000 
1,000 
1,000 
2,000 
2,000 
2,000 
2,000 
2,000 


$7 

$1.20 

10 

1.60 

15 

2.20 

20 

2.80 

30 

3.90 

7 

1.50 

10 

1.90 

15 

2.50 

20 

3.10 

30 

4.20 

$14. 10 
19.20 
26.40 
33.60 
46.80 
18.00 
22.80 
30.00 
37.20 
50.40 


*  The  same  principle  is  applied  to  the  scale  for  amounts  ranging  to  $4,000. 

Forfeiture  of  benefits  occurs  when  the  member  engages  in  a  more 
hazardous  occupation,  assumes  "risks  to  which  members  of  the  trade  are 
not  usually  liable,"  receives  injury  while  intoxicated,  or  when  he  is  in 
arrears  for  dues.  There  were  111,185  union  men  in  the  State  of  Illinois 
in  1917  in  the  national  unions  which  pay  for  permanent  disability. 

Death  Benefits. 

There  are  nine  national  unions  which  provide  death  benefits  under 
an  insurance  policy  contract.^-  All  of  these  operate  in  the  State  of 
Illinois  with  a  membership  of  $35,506.  The  minima  of  these  contracts 
range  from  $300  to  $1,500,  and  the  maxima  from  $1,000  to  $4,500. 
Membership  in  these  funds  may  be  either  optional  or  compulsory,  but 

"  Twenty-third  Annual  Report,  U.  S.  Commissioner  of  Labor,  p.  30. 


558 

III  tile  majority  of  cases  it  is  the  latter,  provided  the  member  is  within 
the  age  limit  and  can  pass  a  physical  examination.  Some  unions 
having  compulsory  insurance  also  provide  for  those  who  are  unable  to 
insure  by  paying  a  funeral   benefit  to   non-beneficiary   and   honorary 

members. 

Among  national  and  local  unions  paying  funeral  benefits  members 
in  good  standing  in  the  union  are  generally  entitled  to  benefits.  How- 
over,  periods  of  membership  varying  from  three  months  to  a  year  are 
frecpiently  made  as  a  requirement  before  benefits  are  paid.  In  order 
to  attract  and  hold  members  the  plan  of  increasing  benefits  with  length 
of  membership  has  been  put  into  effect  in  many  cases.  The  amounts 
may  increase  for  a  period  of  ten  years  and  run  as  high  as  $800.  This 
arrangement  may  be  accompanied  by  a  requirement  for  medical  examin- 
ation and  by  an  age  limit  beyond  which  members  may  not  enter  into  the 
scheme. 

As  stated  above,  173  locals  reporting  indicated  that  they  paid 
death  benefits  in  addition  to  those  provided  by  the  national  union  in 
sum  ranging  from  $20  to  $500.  In  cases  where  the  local  is  an  older 
organization  than  the  national  it  is  likely  that  the  local  death  benefit 
was  established  prior  to  the  national  union  benefit.  A  comparatively 
small  number  of  locals  (62)  reported  that  their  local  benefit  was  the 
only  one  furnished  by  the  union.  Because  of  its  easy  administration 
the  rapid  adoption  of  this  form  of  benefit  by  the  national  unions  has  met 
with  little  opposition. 

The  payment  of  death  benefits  among  the  United  Mine  AVorkers  in 
the  State  of  Illinois  presents  rather  a  unique  situation.  Payment  of 
death  benefits  has  not  been  undertaken  by  the  national  union.  The 
District  organization,  however,  with  its  305  locals  and  90,000  members 
pays  a  benefit  of  $250.  The  Commission  received  reports  from  127  of 
these  locals.  Ninety  of  them  with  a  membership  of  31,577  stated  that 
they  paid  a  local  benefit  in  addition  to  the  District  benefit.  The  local 
benefit  varies  from  $25  to  $500,  but  $100  is  the  most  frequent  benefit 
paid. 

The  local  unions  of  Carpenters,  Miners,  Briekmakers,  Painters  and 
Street  Railway  Employees  frequently  pay  a  death  benefit  in  case  of  the 
deatli  of  a  member's  wife  or  of  his  other  dependents.  The  amounts 
imid  in  event  of  death  of  the  wife  varies  from  $25  to  $125  and  of  children 
from  $10  to  $75. 

Forfeiture  of  death  benefits  is  generally  governed  bv  rules  re- 
garding extra-hazardous  occupation,  taking  risks  other  than  the  ordinary 
trade  risks,  death  caused  by  intemperance,  debauchery,  or  immoral  con- 
duct and  non-payment  of  dues.^* 

Bevcu  ues. 

The  financial  support  of  these  various  benefits  comes  from  entrance 
and  re-instatement  fees,  special  assessments  and  the  regular  union  dues. 
1  he  ontrnnce  fee  paid  to  the  national  union  may  be  either  all  or  part  of 
the  fee  paid  to  the  local  union.^*     Where  insurance  certificates  are  issued 

"  Twenty-third  Annual  Report,  U.   S.   Commissionpr  of  T  nhnr-    r.    "^i 


559 

and  an  insurance  or  benefit  department  is  organized,  fees  are  frequently 
paid  to  the  union  and  to  the  department  or  fund. 

Special  assessments  are  usually  levied  by  the  executive  board  or  by 
a  general  vote  of  the  members  whenever  the  general  or  benefit  fund  has 
fallen  below  a  stated  sum.  The  use  of  this  expedient  introduces  an 
element  of  safety  which  would  not  exist  without  it  in  most  unions. 
Moreover,  it  avoids  the  necessity  of  close  conformity  to  actuarial  princi- 
ples. Also  the  unions  in  working  out  their  main  purpose  of  organizing 
trades  improve  the  security  of  their  funds  by  the  steady  induction  of  the 
young  men  into  the  union.  The  special  assessment  is  also  used  by 
unions  which  make  no  attempt  to  establish  definite  benefits.  Some 
locals  follow  the  practice  of  voting  a  per  capita  tax  whenever  a  member 
is  disabled.  Eighteen  locals  with  a  membership  of  6,061  report  such  a 
provision,  while  ninety-five  locals  with  a  membership  of  28,517  report 
cash  donations  of  varying  sums  and  tax  their  members  to  furnish  these 
amounts. 

The  main  support  of  national  and  local  unions  is  derived  from  the 
regular  union  dues.  In  several  unions  all  the  funds  collected  by  the 
local  "are  retained  in  the  local  treasury,  subject  to  the  call  of  the  national 
officers."^^  This  arrangement  is  accompanied  by  a  scheme  for  the 
equalization  of  funds.  "In  these  unions  only  such  funds  as  are  necessary 
to  the  proper  administration  of  the  general  affairs  of  the  national  union 
are  sent  to  headquarters,  the  benefits  being  paid  from  the  local  treasury 
under  the  supervision  of  the  general  officers ;  and  when  need  occurs  funds 
are  transferred  from  one  local  to  another  at  the  direction  of  the  general 
officers."^® 

Among  the  local  unions  in  the  State  which  have  definite  disable- 
ment benefits  52  per  cent  of  those  reporting  establish  a  general  benefit 
fund  by  the  regular  union  dues.  The  claims  for  disablement  are  met 
out  of  the  general  fund.  Forty-two  per  cent  of  the  locals  follow  the 
practice  of  charging  definite  rates  to  establish  a  disablement  fund. 
These  rates  vary  from  2y2  to  18  cents  per  week.  Three  per  cent  of 
the  unions  set  aside  for  the  fund  certain  percentages  of  the  regular  dues 
varying  from  5  to  331/3  per  cent.  The  remaining  3  per  cent  made  no 
report.  The  same  rates  are  charged  to  all  members  unless  they  are 
divided  into  classes  with  definite  rates  for  each  class. 

Of  the  locals  which  reported  on  death  benefits  60  per  cent  sup- 
port their  funds  from  the  regular  union  dues,  and  28  per  cent  use 
special  assessments.  The  others  furnished  no  information  upon  this 
point.  Moreover,  only  50  per  cent  stated  that  a  separate  fund  was  kept 
for  death  benefits.  This  practically  typifies  the  situation  among  national 
unions  for  in  a  majority  of  cases  no  separate  benefit  fund  is  established.^^ 

"In  the  majority  of  national  unions  members  are  not  relieved  from 
the  payment  of  contributions,  nor  tnay  their  contributions  to  the  national 
body  be  reduced  for  any  reason;  if  the  local  deems  the  request  for 
admission  or  reduction  of  contributions  a  worthy  one  it  may  act  ac- 
cordingh',  but  the  local  must  pay  to  the  national  body  the  full  contri- 


^^Ihid.,  p.  26. 

18 
17 


IMd.,  p.  26. 

Twenty-third  Ajimial  Report,  U.   S.   Commissioner  of  Labor,  p.  27. 

Twenty-third  Annual  Report,  Commissioner  of  Labor,  p.  25. 


bution  for  the  member.     However,  several  of  the  national  unions  re- 
lieve sick  or  unemployed  members  from  the  payment  of  contributions."^^ 

Admitiistration. 

Among  national  unions  the  usual  custom  is  to  place  the  administra- 
tion of  benefit  funds  in  the  hands  of  the  regular  officials.  In  some  cases 
where  there  is  a  mutual  benefit  department,  it  is  administered  by  separate 
officers."  Under  both  systems  the  officers  directly  responsible  for  funds 
are  generally  bonded  and  hold  their  positions  through  election  by  a 
general  convention  or  a  general  vote.  Such  officials,  moreover,  are  sub- 
ject to  supervision  by  the  executive  board  or  council. 

Of  the  locals  reiEX>rting  only  12  per  cent  stated  that  the  adminis- 
tration of  their  local  funds  was  supervised  by  the  nationar organization. 
However,  in  82  per  cent  of  the  locals  it  was  reported  that  the  funds  were 
frequently  audited.  The  period  of  audit  varied  from  once  a  year  to  once 
ever}'  month.     In  a  majority  of  the  cases  audit  was  quarterly. 

The  supervision  of  claims  may  be  either  in  the  hands  of  the  officers 
or  of  a  visiting  committee,  more  frequently  the  latter.  In  68  per  cent 
of  the  locals  reporting  their  efforts  are  supplemented  by  the  requirement 
of  a  physician's  certificate  as  proof  of  claim  to  benefits. 

The  committee  may  be  either  elected  or  appointed  and  the  members 
may  be  required  to  serve  and  to  be  subject  to  penalty  for  neglect  of  duty. 
The  difficulties  of  this  form  of  administration  of  claims  are  apt  to  be 
accentuated  wherever  the  sickness  benefits  are  paid  by  the  superior 
jurisdiction.  Laxity  on  the  part  of  the  local  administration  has  been 
known  to  compel  the  national  unions  to  institute  campaigns  against 
malingering  in  order  to  protect  their  funds  and  to  remind  locals  that  they 
would  be  subject  to  higher  dues  to  meet  the  growing  claims  to  benefit.^^ 
On  the  other  hand  where  the  local  members  are  few  in  number  and  each 
is  well  known  among  his  fellows  there  should  be  little  difficulty  in 
determining  the  validity  of  claims.  At  the  same  time  it  may  be  a  means 
of  preserving  and  developing  the  fraternal  feeling  so  essential  to 
unionism.  In  G2  per  cent  of  the  locals  the  member  is  given  the  right 
of  appeal  to  the  officials  or  to  the  union  as  to  the  validity  of  his  claim. 

CoiK-lusion. 

What  are  the  conclusions  that  may  legitimately  be  draw^n  from  this 
survey  of  the  operation  of  trade  union  funds  in  the  State  of  Illinois? 
As  a  means  of  mutual  protection  and  of  encouraging  allegiance  to  the 
union  they  have  proven  their  worth.  But  considerations  of  adequacv 
immediately  call  attention  to  the  need  for  further  elaboration  and  greater 
comprehensiveness  if  the  funds  are  properly  to  care  for  the  burden  of 
sickness. 

Among  most  funds  the  rates  of  benefit  are  too  low  to  care  adequatelv 
for  the  needs  of  the  worker  and  his  family  when  his  wages  are  cut  off. 
^^"  '^  ^^^  maximum  period  of  payment  long  enough  in  most  union 

»*Ibld..  p.  27. 

"R^norroT^th;  SStIfn?v,"l^**'^^  Engineers  and  Letter  Carriers. 
p.  42.  Sixteenth  Convention.  1917,  Bakers  and  Confectionery  Workers. 


561 

funds  to  provide  for  the  cases  where  illness  is  prolonged.  Although 
the  length  of  the  waiting  period  is  usually  short  enough  to  include  the 
greater  number  of  short  illnesses,  there  is  still  room  for  much  improve- 
ment in  this  respect. 

Moreover,  there  is  almost  an  entire  absence  of  provision  for  medical 
and  hospital  care.  Eyerything  points  to  the  need  of  such  treatment  to 
supplement  the  money  payments  which  help  the  family  to  ward  off 
poverty. 

More  important  than  all  these  considerations  is  the  fact  that  com- 
paratively few  of  the  working  population  are  protected  by  either  trade 
union  or  establishment  funds.  As  a  rule  it  is  only  the  skilled  workmen 
that  are  protected  by  trade  union  funds  and  the  majority  of  these  are 
not  insured  against  temporary  and  prolonged  disability.  Although  a 
high  percentage  of  trade  unionists  receive  death  benefits,  in  the  great 
majority  of  cases  the  amount  is  small. 

In  short  there  is  every  indication  of  a  need  for  amplification  of 
trade  union  benefits  and  for  the  inclusion  of  other  features  of  pro- 
tection which  will  supplement  what  is  already  being  done. 


—36  H  I 


562 


SPECIAL     REPORT     XIII.     THE     PRESENT     STATUS     OF 
HEALTH     WORK     IN     THE     PUBLIC     SCHOOLS     OF 

ILLINOIS. 

(By  W.  G.  Beeder.) 


INote  by  the  Secretary.— The  children  of  today  will  be  workers  of  the  next 
ireneration  Their  efficiency  and  mode  of  life  then  as  well  as  their  health  while 
pupils  depend  to  a  considerable  extent  upon  the  medical  care  and  supervision  pro- 
vided by  the  school  authorities.  Realizing  the  importance  of  such  provision,  the 
Commission  arranged  with  Mr.  W.  G.  Reeder  of  the  School  of  Education,  the  Uni- 
versity of  Chicago,  to  ascertain  what  provision  is  being  made  by  the  school  authori- 
ties of  this  State  for  medical  inspection,  nursing,  and  clinical  treatment  of  school 
children.     The  results  of  his  general  survey  are  set  forth  in  the  following  report.] 

I.  Introduction.  . 

Medical  inspection,  nursing  and  clinics  in  the  schools  are  no  longer 
in  the  experimental  stage  in  Illinois,  the  United  States,  or  in  foreign 
countries.  In  this  country  medical  inspection  of  school  children  is 
being  widely  practiced.  It  has  been  national  in  scope  for  many  years 
in  France,  England,  Belgium,  Sweden,  Switzerland,  and  Japan.  It 
is  found  in  some  degree  in  Austria-Hungary,  Bulgaria,  Germany,  Russia, 
Australia,  Denmark,  Norway,  Roumania,  Canada,  Mexico,  Argentine 
and   Chile. 

Japan  has  long  been  one  of  the  leaders  in  the  school  hygiene  move- 
ment, as  the  following  description  of  her  system  will  attest. 

"The  Japanese  system  of  medical  inspection  extends  all  over  the 
empire  and  reaches  the  most  remote  rural  community.  Thus  the 
Japanese  department  of  education  is  able  to  tell  how  many  children  are 
in  the  schools  of  the  empire,  how  many  are  robust,  medium,  or  weak, 
how  many  have  defective  eyesight,  and  what  diseases  are  most  prevalent 
at  different  ages  of  school  life.  The  department  can  tell  how  many 
children  in  school,  at  the  age  of  fifteen  years,  were  150  cm.  tall,  how 
many  weighed  40  kg.,  and  how  many  had  a  chest  measurement  of  75 
cm.  They  can  also  tell  the  averages  of  all  these  statistics  and  the  per- 
centages of  robust  boys  or  fat  girls."^ 

English  practice.— ~ln  Europe,  England  furnishes  the  best  example 
of  legislative  enactments  under  which  theory  and  practice  of  educators 
and  physicians  have  been  crystallized  in  the  field  of  school  hygiene.  In 
view  of  the  fact  that  the  English  statute  has  been  widely  copied,  es- 
pecially m  the  laws  of  other  nations,  it  seems  worth  while  to  quote  it 
in  extenso.  It  is  known  legally  as  Section  13  of  the  Administrative 
Provisions  of  the  Education  Act  of  1907,  and  reads  as  follows : 

1  ^^'  X  CVx  ^i^®  powers  and  duties  of  a  local  education  authority 
under  Part  HI  of  the  Education  Act,  1902,  shall  include;  <a)  Power  to 
provide   for   children    attending   public    elementary   schools,    vacation 

28,  et^seq.'^^'  ^'  ^'  ^"'^  ^^''^^'  ^-  ^'  ^^^ic<^^  Inspection  of  Schools,  ed.,   1908,   p. 


563 

schools,  vacation  classes,  play  centers,  etc.  (b)  The  duty  to  provide 
for  the  medical  inspection  of  children  immediately  before  or  at  the  time 
of  or  as  soon  as  possible  after  their  admission  to  a  public  elementary 
school,  and  on  such  occasions  as  the  Board  of  Education  direct,  and  the 
power  to  make  such  arrangements  as  may  be  sanctioned  by  the  Board  of 
Education  for  attending  to  the  health  and  physical  condition  of  the 
children  educated  in  public  elementary  schools:  Provided,  that  in  any 
exercise  of  powers  under  this  section  the  local  education  authority  may 
encourage  and  assist  the  establishment  or  continuance  of  voluntary 
agencies,  and  associate  with  itself  representatives  of  voluntary  associa- 
tions for  the  purpose. 

"(2)  This  section  shall  com(?  into  operation  on  the  first  day  of 
January,  nineteen  hundred  and  eight." 

The  use  being  made  of  the  powers  thus  conferred  is  shown  by  the 
following  details  taken  from  the  most  recent  report  of  the  Chief  Medical 
Officer  of  the  Board  of  Education. 

"The  number  of  medical  officers,  "whole-time"  and  "part-time,"  en- 
gaged in  1916  in  the  work  of  the  School  Medical  Service  was  approxi- 
mately 1,213,  of  whom  441  were  employed  on  work  of  a  specialist  char- 
acter. Of  the  remaining  772 — which  figure  represents  the  number  of 
doctors  holding  appointments  as  School  Medical  Officers  and  Assistant 
School  Medical  Officers — 122  were  women  working  in  65  different  areas, 
70  being  "whole-time"  officers.  In  addition,  there  were  193  medical 
practitioners  who  undertook  work  at  the  London  Treatment  Centers. 
It  is  also  interesting  to  note  that  seven  women  were  employed  in  five 
areas,  and  that,  according  to  the  Board's  records,  there  were  1,527 
School  Nurses  employed  by  286  Authorities."^ 

Other  illustrative  details  found  in  this  report  are  that  219  of  the 
local  educational  authorities  were  operating  48-0  school  clinics;  146 
authorities  were  operating  295  dental  clinics ;  221  were  providing  for 
the  treatment  of  errors  of  refraction  and  other  ophthalmic  work,  and 
in  189  of  these  areas  spectacles  were  provided  free  or  at  reduced  rates; 
87  local  authorities  contributed  to  hospitals  with'  which  arrangements  \ 
had  been  made  for  the  care  of  school  children ;  and  24  residential  sani-  j 
tarium  schools  were  being  operated  for  the  tubercular. 

These  things,  together  with  many  others,  w^ere  being  done  by  En- 
gland right  through  the  stress  of  the  World  War,  thus  showing  that  the 
medical  inspection  of  schools  is  regarded  as  absolutely  essential  for  the 
future  strength  of  the  nation.  What  the  English  think  of  the  efficacy 
of  their  School  Medical  Service  is  evident  from  the  following : 

"The  School  Medical  Service  has  won  its  way  not  only  by  the  en- 
terprise, skill,  and  devotion  of  the  Local  Education  Authorities  and 
their  officers — doctors,  nurses,  teachers — but  by  its  own  natural  mo- 
mentum. The  objections  raised  at  its  initiation  have  diminished  almost 
to  a  vanishing  point.  Its  fruits  are  both  its  reward  and  its  promise. 
To-day  hundreds  of  thousands  of  children  are  healthier,  better,  and 
brighter  for  its  labours.  In  large  towns  and  in  small  country  villages 
there  has  arisen  something  of  a  new  understanding  of  the  child.     He  is 

2  Annual  Report  for  1916  of  the  Chief  Medical  Officer  of  the  Board  of  Education, 
p.  4. 


564 

coming  steadily  into   his  kingdom,   into  his   individual   birthright   of 

health  and  well  being/'^ 

Any  Commonwealth  might  profitably  consider,  as  a  guidmg  policy 
in  health  supervision  of  school  children,  the  principles  set  forth  in  this 
British  report.     They  are  stated  as  follows: 

"(1)  That  every  child  shall  periodically  come  under  direct  medical 
and  dental  supervision,  and  if  found  defective  shall  be  'followed  up;' 

"(2)  That  every  child  found  mal-nourished  shall^  somehow  or 
other,  be  nourished,  and  every  child  found  verminous  shall  somehow 
or  other,  be  cleansed; 

"(3)  That  for  every  sick,  diseased,  or  defective  child,  skilled  med- 
ical treatment  shall  be  made  available,  either  by  the  Local  Education 
Authority  or  otherwise; 

"(4)  That  every  child  shall  be  educated  in  a  well-ventilated  school- 
room or  classroom,  or  in  some  form  of  open-air  schoolroom  or  class- 
room; 

"(5)  That  every  child  shall  have,  daily,  organized  physical  exer- 
cise of  appropriate  character; 

"(6)  That  no  child  of  school  age  shall  be  employed  for  profit  ex- 
cept under  approved  conditions; 

"(7)  That  the  school  environment  and  the  means  of  education  shall 
be  such  as  can  in  no  case  exert  unfavourable  or  injurious  influences  upon 
the  health,  growth,  and  development  of  the  child/'* 

These  form  the  basis  for  a  formidable  policy  of  Child  Welfare  to- 
ward which  the  most  enlightened  states  and  nations  are  continually  mak- 
ing progress.  The  state  that  works  toward  the  consummation  of  these 
steps  must  indeed  have  accepted  the  philosophy  of  Gladstone  when  he 
says,  "In  the  health  of  the  people  lies  the  wealth  of  the  nation." 

What  other  states  are  doing. — Medical  inspection  has  had  a  more 
recent  and  less  extensive  development  in  the  United  States  than  in  En- 
gland and  other  European  countries.  Boston  (in  1894)  was  the  first 
city  to  establish  it  as  a  regular  phase  of  school  work.  Chicago  began 
!the  work  in  1895,  New  York  City  in  1897,  and  Philadelphia  and  St. 
Louis  in  1898.  The  movement  has  spread  from  the  larger  cities  to  the 
smaller;  indeed  in  several  states  it  is  state-wide  under  mandatory  stat- 
utes, as  the  following  resume^  of  legislation  shows. 

Connecticut  enacted  the  first  state  law  concerning  health  work  in 
the  schools  in  1899.  This  first  law  simply  required  that  teachers,  un- 
der the  supervision  of  the  State  Board  of  Education,  should  test  the 
eyesight  of  children  every  three  years.  Since  then  state  legislation  on 
this  subject  has  moved  apace,  developing  from  a  inere  feeling  of  doubt- 
ful utility  into  a  fixed  principle  of  medical  economics  and  preventive 
hygien/. 

At  present  (191S)  25  states  have  legislated  on  this  subject.  Of 
these  states,  12  have  statutes  which  may  be  characterized  as  manda- 
tory,  while  13  have  permissive  laws.     The  movement  has  been  from 

"Op.  cit.  p.  VI,  ff. 
♦Ibid.,  pp.  ix-x. 

•The  daU  concerning  other  states  were  gotten  by  an  examination  of  the  school 
laws  of  each  state  and  by  correspondence  with  the  chief  state  school  official  of  each 
state. 


565 

permissive  to  mandatory  statutes.     Table  I  below  is  designed  to  show 
the  principal  features  of  the  present  state  legislation  on  this  subject. 

TABLE     I— PRINCIPAL     FEATURES     OF     STATE     LAWS     PROVIDING     FOR 
HEALTH    SUPERVISION    OF    SCHOOL    CHILDREN,    1918.* 


a 


state. 


Date 
adopted. 


CO 

1 

, 

.1 

>. 

o 

03 

CI 

1 

t-l 

ed  in 
ng  tests 

o 

o 

o 

t— 1 

s 

TS 

a'C 

o 

o 

C3 

s 

fl 

•^  cS 

e3 

J3     , 

o 

OT    fli 

t3 

a 

o 

-§5 

C/) 

CO  en 

to 

>> 

ft 

C8 

CO 
CO 

1  students  tr 
g  sight  and  h 

> 

'en 

a  . 

CO    ^ 

2 

M 

C  -"-^ 

fa  c3 

fa  =5 

« 

03  Cl 

a 

'S'S 

O  <» 

8^ 

O  o 
5  o3 

o 

k4 

o 

g3 
© 

CM 

<1 

Q 

Q 

PL, 

E-t 

Z 

To  what  districts 
the  law  applies. 


California . . . 

Colorado 

Connecticut . 

Georgia 

Indiana 

Louisiana . . 
Maine 


Maryland . 


9  Massachusetts . . . 

10  Montana 

11  Nevada 

12  New  Hampshire. 

13  New  Jersey , 

14  New  York 

15  North  Carolina . . 

16  North  Dakota . . . 

17  Ohio 

18  Pennsylvania  . . . 


19 


20 
21 

22 

23 
24 

25 


Rhode  Island....  1911,15,17 


1909 

1909 

1899,1907. 

1914 

1911 

1908 

1909 


1914. 


1906, 1908. 

1917 

1917 

1913 

1909 

1910,1913. 

1917 

1915 

1910,1913. 
1911 


Utah.... 
Vermont . 

Virginia. 


Washington 

West  Virginia . . . 

Wyoming 


1911. 
1910. 

1908- 

1909. 
1911. 

1915. 


P. 
M. 
P. 
P. 
P. 
M. 
M. 

P. 

M, 
P. 
M. 
P. 
M 
M 
M 
P 
P. 
&M 


M. 
P. 

P. 

P. 

P.  &M. 

M. 


S, 
S, 

s, 

S.  &  H, 

s, 

S.  &  H. 

s. 


S.  or  H 
S.  &  H 

S, 

s, 
s. 

s. 

S.  &  H, 

s, 

S.  or  H, 

S. 


s. 


•    s. 


X 


X 
X 
X 


X 
X 
X 


X 
X 
X 
X 
X 
X 
X 


X 


Broad 

enough 

X 

X 


X 


X 
X 
X 


X 
X 
X 


X 
X 
X 
X 
X 
X 
X 


X 


X 
X 


Broad 

enough 

X 

X 


X 
X 


X 

x 


X 

Phys. 
X 
X 
X 

Xor 
Phys. 

Xor 

Phys. 

X 


X 
X 

Phys. 
X 


X 
X 


X 


X 


Phys 
X 


X 
X 


X 


X 


Where  adopted. 

All. 

Where  adopted. 

Where  adopted. 

Where  adopted. 

All. 

Cities  under  40,000. 

Where  adopted. 

All. 

Where  adopted. 

All. 

Where  adopted. 

All. 

All. 

All. 

Where  adopted. 

Where  adopted. 

Man.  in  1st  and  2d, 

per.  in  3d  and  4th 

class  cities. 
Where  adopted; 

sight  and  hearing 

all. 
All. 
Where  voted;  sight 

and  hearing  all. 
Where  adopted. 

1st  class  cities. 
Man  in  cities;  per  in 

rural  districts. 
Cities  and  towns 

only. 


*  In  addition  to  the  states  indicated  in  the  foregoing  table,  a  few  others  give 
the  boards  of  health  legal  right  to  promulgate  rules  and  regulations.  Since  these 
go  no  further  than  the  control  of  contagious  diseases,  especially  in  time  of  epi- 
demics, it  does  not  seem  worth  while  to  include  them  in  the  list.  The  table  is 
meant  to  give  only  a  general  idea  of  the  different  legislation,  and  for  completeness 
and  qualifications  the  laws  themselves  should  be  examined. 

Besides  the  dates  when  the  several  statutes  were  adopted  and 
whether  these  are  permissive  or  mandatory,  the  table  shows : 

1.  The  carrying  out  of  tTie  provisions  of  the  law  is  usually  placed 
in  the  hands  of  the  school  authorities; 

2.  Provision  is  made  for  physicians  to  examine  pupils  for  con- 
tagious diseases  and  physical  defects;  a  lesser  number  of  laws  provide 
for  the  examination  of  teachers,  janitors,  and  school  buildings; 


566 


3.  Provision  is  made  for  the  teachers  to  give  sight  and  hearing 
tests,  under  proper  direction;  a  lesser  number  of  states  provide  that 
normal  students  be  trained  in  giving  these  tests; 

4.  School  nurses  are  specifically  provided  for,  or  else  the  law  is 
broad  enough  to  include  them. 

Though  a  common  vein  runs  through  practically  all  the  laws,  they 
differ  in  detail,  as  in  provision  for :  vaccination  of  pupils  and  teachers ; 
exclusion  from  school  of  pupils  and  teachers  in  times  of  epidemics,  etc. ; 
penalty  for  violation  of  tlie  law ;  medical  and  dental  care ;  Chief  Medical 
Director  of  Schools ;  appropriations  for  the  work ;  communities  to  which 
the  law  applies;  and  follow-up  work,  and  the  duty  of  parents. 

Since  the  Massachusetts  law  has  been  used  as  the  basis  for  a 
majority  of  the  bills  which  have  been  presented  in  our  state  legislatures, 
it  seems  worth  while  to  quote  it  in  extenso.  The  law  (Chapter  502, 
Acts  of  1906)  reads  as  follows: 

AN  ACT  RELATIVE  TO  THE  APPOINTMENT  OF  SCHOOL  PHYSICIANS. 

Be  it  enacted,  etc.,  as  follows: 

Section  1.  The  school  committee  of  every  city  and  town  in  the 
Commonwealth  shall  appoint  one  or  more  school  physicians,  shall  assign 
one  to  each  public  school  within  its  city  or  town,  and  shall  provide  them 
with  all  proper  facilities  for  the  performance  of  their  duties  as  pre- 
scribed in  this  Act;  provided,  however,  that  in  cities  wherein  the  board 
of  health  is  already  maintaining  or  shall  hereafter  maintain  substan- 
tially such  medical  inspection  as  this  Act  requires,  the  board  of  health 
shall  appoint  and  assign  the  school  physician. 

Section  2.  Every  school  physician  shall  make  a  prompt  examination 
and  diagnosis  of  all  children  referred  to  him  as  hereinafter  provided, 
and  such  further  examination  of  teachers,  janitors  and  school  buildings 
as  in  his  opinion  the  protection  of  the  health  of  the  pupils  may  require. 

Section  3.  The  school  committee  shall  cause  to  be  referred  to  a 
school  physician  for  examination  and  diagnosis  every  child  returning  to 
school  without  a  certificate  from  the  board  of  health  after  absence  on 
account  of  illness  or  from  unknown  cause ;  and  every  child  in  the  schools 
under  its  jurisdiction  who  shows  signs  of  being  in  ill  health  or  of  suf- 
fering from  infectious  or  contagious  disease,  unless  he  is  at  once  excluded 
from  the  school  by  the  teacher ;  except  that  in  case  of  schools  in  remote 
and  isolated  situations  the  school  committee  may  make  such  other  ar- 
rangements as  may  best  carry  out  the  purposes  of  this  act. 

Section  4.  The  school  committee  shall  cause  notice  of  the  disease 
or  defects,  if  any,  from  which  any  child  is  found  to  be  suffering  to  be 
sent  to  his  parent  or  guardian.  Whenever  a  child  shows  symptoms  of 
small  pox,  scarlet  fever,  measles,  chickenpox,  tuberculosis,  diphtheria  or 
influenza,  tonsilitis,  whooping  cough,  mumps,  scabies  or  trachoma,  he 
shall  be  sent  home  immediately,  or  as  soon  as  safe  and  proper  convey- 
ance can  be  found,  and  the  board  of  health  shall  at  once  be  notified. 

Section  5.  The  school  committee  of  every  city  and  town  shall  cause 
every  child  in  the  public  schools  .to  be  separately  and  carefully  tested 
and  examined  at  least  once  in  every  school  year  to  ascertain  whether 
he  is  suffering  from  defective  sight  or  hearing  or  from  any  other  dis- 
ability or  defect  tending  to  prevent  his  receiving  the  full  benefit  of  his 


567 

school  work  in  order  to  prevent  injury  to  the  child  or  to  secure  the  best 
educational  results.  The  tests  of  sight  and  hearing  shall  be  made  by 
teachers.  The  committee  shall  cause  notice  of  any  defect  or  disability 
requiring  treatment  to  be  sent  to  the  parent  or  guardian  of  the  child, 
and  shall  require  a  physical  record  of  each  child  to  be  kept  in  such  a 
form  as  the  state  board  of  education  shall  prescribe. 

Section  6.  The  state  board  of  health  shall  prescribe  the  directions 
for  tests  of  sight  and  hearing  and  the  state  board  of  education  shall, 
after  consultation  with  the  state  board  of  health,  prescribe  and  furnish 
to  school  committees  suitable  rules  of  instruction,  test-cards,  blanks, 
record  books,  and  other  useful  appliances  for  can-ying  out  the  purpose 
of  this  act,  and  shall  provide  for  pupils  in  the  normal  schools  instruction 
and  practice  in  the  best  methods  of  testing  the  sight  and  hearing  of 
children.  The  state  board  of  education  may  expend  during  the  year 
nineteen  hundred  and  six  a  sum  not  greater  than  fifteen  iiundred 
dollars,  and  annually  thereafter  a  sum  not  greater  than  five  hundred 
dollars  for  the  purpose  of  supplying  the  material  required  by  this  act. 

Section  7.  The  expenses  which  a  city  or  town  may  incur  by  virtue 
of  the  authority  herein  vested  in  the  school  committee  or  board  of 
health,  as  the  case  may  be,  shall  not  exceed  the  amount  appropriated 
for  that  purpose  in  cities  by  the  city  council  and  in  towns  by  a  town 
meeting.  The  appropriation  shall  precede  any  expenditure  or  any  in- 
debtedness which  may  be  incurred  under  this  act,  and  the  sum  appro- 
priated shall  be  deemed  a  sufficient  appropriation  in  the  municipality 
where  it  is  made.  Such  appropriation  need  not  specify  to  what  section 
of  this  act  it  shall  apply,  and  may  be  voted  as  a  total  appropriation  to 
be  applied  in  carrying  out  the  purposes  of  this  act. 

Section  8.  This  act  shall  take  effect  on  the  first  day  of  September 
in  the  year  nineteen  hundred  and  six.     (Approved  June  20,   1906.) 

Under  the  provisions  of  Section  7,  many  communities  failed  to  make 
any  appropriation,  consequently  no  inspection  service  was  established 
in  some  places.  This  section  was  repealed  in  1908,  so  that  now  the 
work  is  carried  out  to  some  extent  in  nearly  every  city  and  town  in 
the  Commonwealth.® 

The  experience  of  other  states  and  countries  suggests  that  new 
state  legislation  for  the  proper  health  supervision  of  srchool  children 
should  include  the  following:'' 

1.  Provision  that  the  administration  of  the  system  be  in  the  hands 
of  the  school  authorities,  but  that  they  be  empowered  to  delegate  their 
authority  to  the  local  health  officials,  and  that  in  the  treatment  of  cases 
of  contagious  diseases  the  school  and  health  authorities  shall  cooperate. 
Provision  should  be  made  for  the  Health  Department  of  any  city  to 
continue  the  administration  of  the  system,  so  long  as  the  requirements 
of  the  law  are  met. 

2.  Provision  for  inspection  by  school  physicians  to  detect  and 
exclude  those  with  contagious  diseases. 

3.  Provision  for  annual  physical  examination  of  all  pupils  by 
school  physicians  to   detect   any  physical   defects   which  may  prevent 

*  Resume  of  the  Present  Status  of  Medical  Supervision  of  School  Children  in 
Massachusetts,  p.  5. 

^Chiefly  from  Gulick  and  Ayres,  Medical  Inspection  of  SchoolSj  ed.,  1913,  p. 
171,  et  seq. 


568 

the  children  from  receiving  the  full  benefit  of  their  school  work  or 
which  may  require  that  the  work  be  modified  to  avoid  injury  to  them. 
Provision  for  correcting  such  defects  should  be  made. 

4.  Provision  that  teachers  give  sight  and  hearing  tests  annually, 
and  under  proper  direction. 

5.  Provision  that  students  in  normal  schools  shall  receive  train- 
ing in  giving  sight  and  hearing  tests. 

G.  Provision  that  school  physicians  may  examine  teachers,  janitors, 

and  school  buildings. 

7.  Provision  for  the  employment  of  school  nurses. 

8.  Provision  for  medical  and  dental  care,  and  clinics,  especially 

for  indigents. 

9.  Provision  for  better  standards  in  hygiene  and  physical  training 
as  now  taught  in  the  schools. 

10.  Provision  for  a  Director  of  Educational  Hygiene  in  the  state, 
working  in  cooperation  with  the  office  of  the  State  Superintendent  of 
Public  Instruction. 

11.  Provision  for  adequate  funds  to  carry  out  the  health  super- 
vision policy,  perhaps  a  separate  fund.^ 

12.  Provision  for  enforcing  the  law. 

These  provisions  would  be  in  general  harmony  with  the  spirit  of 
resolutions  adopted  by  the  Conference  of  State  and  Provincial  Boards 
of  Health,  Los  Angeles,  California,  in  July,  1911,  as  follows : 

"We  endorse  legislation  providing  for  the  medical  inspection  of 
schools,  because  extended  and  varied  experience  has  demonstrated  that 
efficient  medical  inspection  betters  health  conditions  among  school 
children,  safeguards  them  from  disease,  renders  them  healthier,  happier 
and  more  vigorous,  and  aims  to  insure  for  each  child  such  physical  and 
mental  vitality  as  will  best  enable  him  to  take  full  advantage  of  the  free 
education  offered  by  the  state. 

"It  is  our  judgment  that  every  law  providing  for  the  medical  in- 
spection of  schools  should  also  make  provision  for  frequent  inspections 
ot  the  children  by  duly  qualified  school  ph3^sicians  to  detect  and  ex- 
clude cases  of  contagious  disease. 

"It  should  further  provide  for  annual  physical  examinations  of 
all  the  children  by  school  physicians  to  detect  any  physical  defects  which 
may  prevent  the  children  from  receiving  the  full  benefit  of  their  school 
work  or  which  may  require  that  the  work  be  modified  to  avoid  injury 
to  the  child. 

"It  should  empower  school  physicians  to  conduct  examinations  of 
teachers  and  janitors  and  to  make  regular  inspections  of  buildings, 
premises  and  drinking  water  to  insure  their  sanitary  condition. 

"We  endorse  the  school  nurse  as  a  most  valuable  adjunct  of  medical 
inspection  and  believe  that  provision  for  the  employment  of  school 
nurses  should  be  included  in  each  law." 

II.  What  Illinois  is  Doing. 

The  main  body  of  this  report  presents  the  results  of  a  study  under- 
taken to  discover  what  the  schools  of  Illinois  are  doing  to  promote 

•  Many  superintendents  In  nilnols  stated  they  were  doing  nothing  in  health  woik 
because  of  lack  of  funds  ;  others  stated  they  would  do  more  if  they  had  the  funds. 


569 

health.  The  facts  for  the  study  were  secured  chiefly  through  question- 
naires. Some  of  the  information,  however,  was  gathered  by  personal 
visitation,  and,  in  addition,  a  large  body  of  statistics  were  obtained  from 
the  offices  of  the  State  Superintendent  of  Public  Instruction  and  the 
State  Department  of  Health  at  Springfield. 

The  results  of  the  study  should  be  considered  in  the  light  of  the 
meagerness  of  data  bearing  upon  the  problem,  and  the  widely  varying 
attention  given  to  the  health  of  school  children  throughout  the  State. 
In  the  absence  of  State  legislation  providing  uniform  standards  of 
medical  inspection,  the  health  supervision  of  school  children  is  left 
entirely  to  local  authorities.  The  effectiveness  of  the  supervision  varies 
from  the  extensive  work  carried  on  by  the  Division  of  Child  Hygiene 
in  the  Department  of  Health  of  Chicago,  to  the  absence  of  any  syste- 
matic supervision  in  the  rural  schools.  In  view  of  these  widely  vary- 
ing conditions  this  study  can  be  but  a  rough  survey  and  should  be  so 
regarded. 

The  investigation  has  been  divided  into  two  parts,  the  one  relating 
to  urban,  the  other  to  rural  schools. 

In  order  to  secure  information  from  all  cities  that  are  doing  some- 
thing toward  health  promotion  work  in  the  schools,  it  was  decided  to 
send  a  questionnaire  to  the  superintendent  of  schools  in  all  places  in  the 
following  groups: 

First,  those  cities  with  a  population  of  5,000  or  over  as  shown  by 
the  census  of  1910;  second,  cities  and  villages  with  a  smaller  population 
reported  by  the  county  superintendents  as  having  school  physicians  or 
nurses;  third,  township  high  schools  located  in  the  cities  of  the  first 
two  groups.  Questionnaires  sent  to  70  in  the  first  group  brought  65 
replies ;  to  30  in  the  second  group,  24  replies ;  to  32  in  the  third  group, 
21  replies. 

Thus,  there  were  sent  to  city  superintendents  and  high  school 
principals  132  questionnaires  from  which  110  replies  were  received. 

To  get  a  general  survey  of  what  the  rural  schools  are^  doing  in 
health  promotion  work,  as  well  as  to  help  make  up  the  list  of  cities  in 
the  second  group  above,  a  short  questionnaire  was  sent  to  each  of  the 
102  county  superintendents  of  schools.  From  these  99  replies  were 
received. 

Though  Illinois  is  one  of  the  few  states  not  having  legislation  for 
the  health  supervision  of  school  children  it  may  not  be  gainsaid  that 
protection  for  the  safety  of  these  has  been  entirely  lacking  as  the  fol- 
lowing paragraph  resume  of  legislation  will  attest. 

In  1877,  the  Legislature  passed  a  bill  to  prevent  and  punish  those 
doing  wrongs  to  children.  Subsequently,  legislation  has  been  enacted 
requiring  the  teaching  of  physiology  and  hygiene;  and  proper  hygienic, 
sanitary,  and  safety  conditions  in  all  public  school  buildings  (1909, 
1915)  ;  prohibiting  the  use  of  a  common  drinking  cup  in  all  schools 
and  public  places  (1911)  ;  providing  for  the  education  of  crippled, 
deaf  and  dumb  and  blind  children  (1911,  1915);  and  requiring  physical 
training  in  the  public  and  in  all  the  normal  schools  (1915).  Illinois 
has  also  a  very  efficiently  organized  Department  of  Public  Health,  which 
has  done  much  to  promote  health  work  in  the  schools.     But  the  State 


570 


is  still  without  legislation  relating  to  the  health  supervision  of  school 

children. 

Without  the  stimulus  of  either  permissive  or  mandatory  legislative 
provision  for  health  supervision  of  school  children,  what  are  the  schools 
of  Illinois  doing  in  an  exercise  of  their  powers  under  the  general  school 
law?  The  following  pages  of  this  report  will  attempt  to  indicate  the 
nature  and  extent  of  their  activities. 

What  the  city  and  village  schools  are  doing. — The  Federal  Census 
of  1910  reports  in  Illinois  a  total  of  1,605  cities  and  villages  with  a 
population  of  100  or  over.  Of  these,  1,240  have  populations  between 
100  and  999;  295  have  populations  between  1,000  and  4,999,  and  70 
have  populations  of  5,000  or  over. 

This  wide  variation  in  population,  with  accompanying  variation  in 
school  population,  suggests  a  wide  range  of  problems  to  be  met  in  at- 
tempting to  survey  the  present  status  of  school  hygiene  work  in  this 
State,  especially  since  there  is  no  legislative  provision  for  a  standard 
plan. 

In  this  resume  it  is  assumed  that  each  of  the  above  communities 
has  a  public  school;  those  that  do  not  are  negligible  in  number,  and 
are  probably  offset  by  those  villages  of  less  than  100  having  a  public 
school,  but  not  included  in  the  above  list.  In  most  phases  of  health 
work  our  data  probably  take  account  of  practically  all  places  doing 
systematic  work  in  the  various  activities.  In  such  activities  as  teach- 
ing hygiene  and  physical  training,  however,  our  data  are  probably  repre- 
sentative only. 

School  physicians  and  physical  examinations. — The  returns  from 
the  investigation  show  that  31  cities  and  villages,  or  about  2  per  cent 
of  the  total,  regularly  employ  school  physicians.  Many  more  indicate 
that  they  have  had  inspections  in  times  of  epidemics  only;  these,  how- 
ever, in  this  study,  are  not  credited  with  having  school  physicians, 
since  it  is  emergency  work,  and  is  usually  done  by  the  local  health 
officer,  and  without  pay,  except  the  little  he  gets  as  salary  as  health 
officer.  Our  tabulations,  in  Table  II  below,  include  only  those  cities 
that  employ  physicians  regularly,  either-  part  or  whole  time.  Only  3 
cities  employ  full-time  physicians,  while  28  employ  part-time  physicians. 

TABLE  II— CITIES  AND  VILLAGES  EMPLOYING  SCHOOL  PHYSICIANS,  AND 

NUMBER  EMPLOYED.! 


Number  of  physicians  employed. 

Cities 

and  villages 

employing 

number 
indicated. 

Total 

number 

employed. 

1* 

20 
3 
5 
2 

1 

♦20 

1 

•} 

2* 

4'in 

3* 

*(i 

8  full-time  plus  149* 

157 

Total...                          

31 

196 

•  Part-time  employees. 

t  Our  data  from  most  places  were  gotten  in  September  just  before  the  influenza 
epidemic.  Data  gathered  .since  would  probably  indicate  a  better  showing  in  both 
^#  f^iP    Pl^y«*c'*"»  ^^^  nurses  (for  nurses,  see  Table  VII),  on  account  of  the  ravages 


571 


Table  III  indicates  a  gradual  increase  each  year  in  the  number  of 
cities  and  villages  having  school  physicians.  Chicago  introduced  them 
as  a  regular  part  of  the  school  activities  in  18-9  5,  being  the  first  in 
Illinois,  and  the  third  city  in  the  United  States.  Evanston  folowed 
in  1900. 


TABLE  III— NUMBER  OF  CITIES  AND  VILLAGES  HAVING  SCHOOL  PHYSI- 
CIANS IN  EACH  YEAR,   1895-1918. 


Year. 

Number 

of  cities  and 

villages. 

1895 

1 

1900 

2 

1910 

4 

1911 

7 

1912 

8 

1913 

9 

1914 

10 

1915 

12 

1916 

14 

1918 

24 

No  date  given  (7) 

31 

Without  attempting  to  discuss  the  question  whether  school  phy- 
sicians should  be  under  the  supervision  of  the  school  or  the  health 
authorities,  Table  I  has  pointed  out  that  it  is  the  policy  of  most  states 
to  place  them  under  the  supervision  of  the  former.  The  practice  of 
Illinois  cities,  as  Table  IV  shows,  conforms  to  this  policy  of  other  states. 
Chicago  is  the  best  known  example  of  health  department  direction  in 
Illinois,  and  one  of  the  best  in  the  United  States. 

TABLE   IV— SUPERVISING  AGENCY  FOR  SCHOOL  PHYSICIANS. 


Supervising  agency. 


Number 

of  cities  and 

villages. 


By  school  authorities 

By  board  of  health 

By  board  of  health  and  school  authorities 
By  private  organization 

Total 


25 
2 
1 

3 


31 


As  might  be  expected,  the  paying  agencies  are  usually  the  same  as 
the  directing  agencies;  in  one  case  only  is  there  an  exception  to  this 
custom.     Table  V  shows  the  paying  agencies  in  full. 


572 


TABLE  V— PAYING  AGENCY  FOR  SCHOOL  PHYSICIANS. 


Paying  agency. 


Number 

of  cities  and 

villages. 


School  authorities 

Board  of  health 

Board  of  health  and  school  authorities 

Endowment 

Gratis 

Total 


25 
1 
1 
3 
1 


31 


From  Table  VI  it  is  evident  that  in  only  a  few  instances  is  the 
salary  sufficient  to  provide  more  than  a  small  part  of  the  physician^s 
living,  which  situation  means  that  in  most  cases  the  physician  will  not 
be  stimulated  to  study  and  improve  himself  in  this  phase  of  pre- 
ventive medicine.  Moreover,  he  will  tend  to  slight  or  neglect  his  school 
work  when  pressed  with  other  duties,  which  primarily  secure  his  living. 
More  places  pay  fees  according  to  service  rendered  than  any  other 
method.  One  city  is  unique  in  that  it  pays  a  given  amount  per  pupil, 
the  amount  being  50  cents. 

TABLE  VI— YEARLY  COMPENSATION  OF  SCHOOL  PHYSICIANS. 


Yearly  compensation. 

Number  of  cities  and 
villages. 

Part-time. 

Full-time. 

Gratis 

1 

1 

10 

Per  pupil 

Fees  according  to  services 

Endowed 

1 

t    100to$    200 

1 
3 

1 
*2 

201  to       300 

301to       500 

601  to    1,000 

1,001  to    1,290 

1 

l,500to   2,000 

1 

Information  incomplete 

9 

Total 

28 

3 

Clans  Se*^^ven'tn\h^' tabie^^^^  group,  but  only  the  salaries  of  the  part-time  physi- 

There  is  no  common  practice  as  regards  the  nature  or  frequency 
of  the  exammation  given  the  pupil.  In  general,  it  seems  to  include 
the  skm,  defects  of  eye,  ear,  nose  and  throat,  heart,  lungs,  and  teeth; 
the  general  condition  is  noted  also.  In  Chicago,  the  examination 
appears  to  be  the  most  thorough  of  any  city. 

From  the  information  gathered,  it  is  apparent  that  the  examination 
varies  in  the  different  cities  from  superficial  to  thorough,  and  its  nature 
and  extent  depend  on  the  conscientiousness  and  ability  of  the  examiner, 
the  number  of  pupils  to  be  examined,  and  the  amount  of  time  spent  in 
the  work.  Usually,  there  is  a  going-over  of  all  pupils  annually  at  the 
beginning  of  the  school  year;  a  few  communities  have  such  examination 
two  or  more  times  during  the  year.  Some  places  report  that,  aside 
from  th€  regular  examination,  the  principal  may   call  the   physician 


573 


at  any  time  when  his  services  are  deemed  necessary.  In  some  half- 
dozen  cases,  the  physical  training  director  gives  each  pupil  a  complete 
physical  examination  each  year. 

School  nurses. — As  shown  by  Table  VII,  there  are  54  communities 
having  the  services  of  a  school  nurse.  This  means  that  about  3  per  cent 
of  the  city  and  village  school  systems  employ  them.  A  few  more  stated 
their  desire  to  introduce  the  work  this  school  year,  but  were  having 
difficulty  in  finding  available  nurses. 


TABLE    VII — CITIES    AND    VILLAGES    EMPLOYING    SCHOOL    NURSES,    AND 

NUMBER  EMPLOYED.! 


Number  of  nurses  employed. 

Cities 

and  villages 

employing 

number 

indicated. 

Total 

number 

employed. 

1* 

11 

37 

4 

1 

1 

*11 

1 

37 

2 

8 

4 

4 

120 

120 

Total...     . 

54 

180 

•  Part-time  nurses. 

t  See  note  on  Table  II. 

The  majority  of  communities  employing  nurses  have  populations 
of  more  than  5,000.  Only  ten  places  smaller  than  this  employ  them. 
There  are  10  communities  having  the  services  of  both  physicians  and 
nurses,  while  75  have  one  or  the  other. 

The  part-time  nurses  give  a  certain  amount  of  time  regularly,  or 
else  do  work  occasionally  as  emergencies  or  special  work  necessitates. 
One  city  (Waukegan)  reports  an  employee  who  serves  part  time  as 
school  nurse,  and  part  time  as  truant  officer. 

Table  VIII  shows  how  the  movement  for  school  nurses,  at  first  slow 
and  gradual,  has  become  in  the  later  years  increasingly  rapid.  As  in 
respect  to  school  physicians,  so  in  respect  to  school  nurses,  Chicago 
was  the  first  Illinois  city  to  use  them.^  Galesburg  followed,  with  the 
employment  of  a  part-time  nurse,  in  1909. 

»In  1901,  nurses  of  the  Visiting  Nursing  Association  began  to  visit  the  crippled 
children  in  four  of  the  public  schools.  It  was  not  until  1908,  however,  that  nurses 
were  employed  by  the  Board  of  Education. 


574 


TABLE    VIII- 


-NUMBER    OF    CITIES    AND    VILLAGES    EMPLOYING    SCHOOL 
NURSES  IN  EACH  YEAR,  1901-1918. 


Year. 


Number 

of  cities  and 

villages. 


1901 

1909 

1910.. 

101 1  . 

I 

I.: 

1914 

1915 

1916 

1917 

1918 

No  date  given  (8) 


1 

2 

5 

7 

8 

9 

14 

20 

29 

35 

46 

54 


As  Table  IX  shows,  in  all  cases  the  paying  and  supervising  agencies 
are  the  same.  The  practice  is  to  have  the  work  directed  and  paid  for 
by  the  school  authorities.  Interest  is  indicated  in  the  school  nursing 
movement  by  the  activity  of  several  private  and  endowed  societies. 

TABLE    IX— SUPERVISING   AND    PAYING   AGENCY   FOR    SCHOOL    NURSES. 


Supervising  aud  paying  agency. 


Number 
of  cities  and 

villages 
under  each 

agency 
indicated. 


School  authorities 

Board  of  health .\...V....... 

Board  of  health  and  school  authorities!  \\[[\[[[[]i 

School  and  private  societies }f' 

Philanthropic  society !!!!!.!!!?" 

Total 


43 
2 
3 
3 
3 


54 


Table  X  shows  that  salaries  of  full-time  nurses  range  in  Illinois 
from  $490  in  the  lowest  instance  to  $1,500  in  the  highest.  More  places 
are  paying  them  at  the  rate  of  between  $791  and  $890  a  year  than  any 
other  amount.  The  average  salary  would  fall  within  the  group  receiv- 
ing from  $891  to  $990.  ^      ^ 


575 


TABLE  X — YEARLY   COMPENSATION   OF   SCHOOL  NURSES. 


Yearly  compensation. 

Number  of 

cities  and  villages  paying 

salary  indicated. 

Full-time. 

Part-time. 

<    191  to  $ 

290 

1 

291  to 

390 

4 

391  to 

490 

3 

491  to 

590 

2 
3 
4 
9 
6 
3 
3 
4 
1 
8 

1 

591 1 9 

690 

691  to 

790 

791  to 

890 

891  to 

990 

991  to   1 

,090 

1,091  to    1 

,290 

1,291  to    1 

,500 

Endowed.. 

No  information .                                                                         

^ 

Total . . 

43 

11 

The  number  of  pupils  under  the  supervision  of  each  nurse  depends 
in  most  instances  on  the  size  of  the  school  enrollment,  since  most  com- 
munities employ  but#  one  nurse.  Authorities  generally  agree  that  a 
feasible  standard  is  about  2,000  pupils^°  per  nurse,  but  the  size  of  the 
school  system  would  need  to  be  considered  in  setting  a  standard.  As 
Table  XI  indicates,  more  cities  have  between  3,001  and  5,000  pupils 
per  nurse  than  any  other  number. 

TABLE  XI— NUMBER  OF  PUPILS  PER  NURSE. 


Pupils  per  nurse. 


Number  of 

cities  and  villages  having 

number  indicated. 


Full-time. 


Part-time. 


Less  than  500 . 
501  to  1,000. 
1,001  to  1,500. 
1,501  to  2, 000. 
2,001  to  2, 500. 
2,501  to  3,000. 
3,001  to  5,000. 
5, 001  and  over 

Total 


4 
3 
1 
1 


11 


In  about  half  of  the  communities  where  nurses  are  employed 
follow-up  work  is  carried  out.  This  work,  though  its  nature  is  not 
specified  except  in  a  few  instances,  generally  has  to  do  with  advising 
the  mother  with  regard  to  defects  found  in  her  child,  accompanying 
pupils  to  places  for  treatment,  securing  glasses,  etc. 

In  one- third  of  the  communities  (18)  the  nurse  visits  each  room 
daily;  in  8,  semi-weekly;  in  10,  weekly;  in "2,  monthly;  and  in  16,  the 
frequency  of  visits  varies.  In  most  instances  the  general  condition  of 
the  pupils  is  noted.     Fifteen  communities  report  that  the  pupils  are 

"  Terman,  L.  M.,  Report  of  the  School  Survey  of  Denver,  Part  V,  p.  62. 


576 

examined  by  the  nurses;  the  things  usually  looked  for  are  skin  dis- 
eases and  pediculosis,  contagious  diseases,  defects  of  eye,  ear,  nose  and 
throat,  and  less  frequently,  the  teeth. 

Dental  climes. — Dr.  William  Osier,  the  distinguished  English 
physician,  said,  "If  I  were  asked  to  say  whether  more  physical  deter- 
ioration was  produced  by  alcohol  or  by  defective  teeth,  I  should  say  un- 
hesitatingly, defective  teeth."  The  fact  that  only  eight  school  systems 
have  dental  clinics  and  employ  dentists  regularly — and  all  these  on  a 
part-time  basis,  excepting  Chicago — shows  that  the  State  has  not  yet 
awakened  to  a  realization  of  the  truth  and  significance  of  Dr.  Osier's 
statement.  Statistics,  which  are  presented  later  in  this  report,  show 
that  decayed  teeth  is  the  commonest  of  all  physical  defects  among  school 
children.^^  Moreover,  there  is  probably  no  defect  among  school  children 
which  causes  so  much  handicap,  misery  and  disease.  These  consider- 
ations would  suggest  the  advisability  of  accelerating  the  development 
of  dental  clinics. 

Eye  clinics. — So  far  as  our  information  goes,  Chicago  is  the  only 
city  maintaining  an  eye  clinic.  At  least  three  other  cities  have  made 
provision  for  regular  ophthalmic  services  on  a  part-time  basis.  Usually 
the  ophthalamic  services  are  given  gratis  to  the  pupils. 

So  far  as  could  be  learned  there  are  no  other  'types  of  school  clinics 
in  operation  in  the  State. 

Outlays  for  health  work. — That  there  is  wide  variation  among  the 
different  cities  in  the  amount  spent  per  pupil  in  health  supervision  is 
evident  from  the  following  table : 

TABLE  XII— TOTAL  EXPENDITURE  PER  PUPIL  FOR  HEALTH  PROMOTION. 


Expenditure  per  pupil. 


Nothing  spent 

f0.006to$0.0.=i 

.06   to     .23 

.26   to     .45 

.46   to     .65 

.86   to     .85 

.86   to   1.05 

1.06   to   1.25 

1.28   to   1.45 

1.46   to   1.65 

Information  incomplete . 


Cities 
and  villages 

expending 
the  amount 

indicated. 


Total . 


25 

12 

29 

15 

7 

4 

2 

2 

1 

3 

10 


110 


The  term  "expenditure,''  as  used  above,  includes  such  items  as 
salaries  of  physicians,  dentists,  ophthalmologists,  and  nurses,  medical 
and  dental  supplies,  printing,  etc.     It  does  not  include  capital  outlays. 

The  expense  of  health  promotion  work  mav  vary  from  the  slight 
cost  of  a  certam  phase  of  the  work,  such  as  giving  sight  and  hearing 
tests  m  one  city,  to  the  high  cost  of  more  extensive  work,  such  as  com- 
plete  physical  examination  and  the  follow-up  work  of  nurses  in  another 

"  See  Table  XXIIL 


577 

city.  Since  the  scope  of  school  health  work  varies  so  widely,  it  is  best 
not  to  generalize  too  definitely  concerning  per  pupil  costs. 

The  per  pupil  cost  varies  from  6  mills  in  the  lowest  case,  where 
anything  is  spent,  to  $1.65  in  the  highest.  More  places  are  spending 
from  6  to  25  cents  per  pupil  than  any  other  amount.  Out  of  the  85 
communities  that  report  having  regular  health  supervision,  56  expend 
45  cents  or  less  per  pupil.  The  best  authorities  report  that  the  better 
systems  of  health  supervision  in  the  cities  of  the  United  States  usually 
cost  from  50  to  75  cents.^^  They  add,  however,  that  $1  or  more  per 
pupil  would  be  a  better  standard,  and  that  anything  less  than  40  cents 
is  almost  certain  to  be  inadequate.^^ 

The  percentage  of  the  school  budget  spent  for  health  supervision 
varies  from  0.01  per  cent  in  the  lowest  instance,  where  anything  is 
spent  to  5.0  per  cent  in  the  highest.  More  cities  are  spending 
between  0.1  and  0.6  per  cent  than  any  other  amount.  In  a  study  of 
25  eastern  cities.  Dr.  Eapeer  found  that  on  an  average  0.9  per  cent  of 
the  school  budget  was  spent  in  health  promotion.^*  This  amount  the 
better  authorities  say  is  usually  too  low.  How  the  cities  of  Illinois 
compare,  in  percentage  of  budget  spent,  with  the  25  eastern  cities  of 
Dr.  Eapeer's  study,  as  well  as  with  one  another,  is  evident  from  Table 
XIII. 

TABLE]   XIII— PERCENTAGE   OP   SCHOOL    BUDGET    SPENT   IN   HEALTH 

SUPERVISION. 


Percentage  of  budget. 

Cities 

and  villages 
spending 
per  cent 

indicated. 

Nothing  spent 

25 

Less  than  0. 1 

10 

0. 1  to  0. 6 

26 

0. 7  to  1, 12 

16 

1. 3  to  1. 8 -  - 

11 

1.9  to  2. 4 

* 

6 

2. 5  to  2. 9 

2 

3. 0  to  3.  5 

2 

Information  incomplete 

12 

Total 

110 

Records. — Table  XIV  shows  that  of  the  85  communities  having 
school  nurses  or  physicians,  39  keep  health  records  of  pupils.  There 
was  no  way  to  judge  the  nature  of  the  records  kept,  except  that  several 
places  sent  forms  which  they  used.  These  forms  show  little  or  no  uni- 
formity, and  it  would  be  utterly  impossible  to  know  accurately  the 
health  condition  in  a  given  community,  and  in  scarcely  any  case  could 
the  nature  and  the  efficiency  of  the  work  in  one  place  be  compared  with 
that  of  others. 

^  Terman,  L.  M.,  Report  of  the  School  Survey  of  Denver,  Part  V,  d.  60. 

"Ibid.,  p.  60. 

"  Rapeer,  L.  W.,  School  Health  Administration,  p.   81. 


-37  H  I 


578 


TABLE    XIV— CITIES    AND    VILLAGES    KEEPING    HEALTH    REvJORDS     OF 

PUPILS. 


Number 

of  cities  and 

villages. 


Keeping  records 

Not  Keeping  records  — 
Information  incomplete 

Total 


39 

66 

5 


110 


Sight  and  hearing  tests. — Since,  as  Table  I  has  indicated,  man}? 
states  require  that  the  sight  and  hearing  of  all  pupils-  be  tested, 
annually,  as  a  rule,  it  is  pertinent  to  indicate  what  the  schools  of  Illinois 
are  doing  without  the  stimulus  of  legislative  enactment.  This  is  done 
in  Table  XV.  The  data  show  that,  where  the  testing  is  done  at  all, 
the  most  common  practice  is  to  do  it  annually;  in  about  a  half  dozen 
cases  it  is  done  more  often. 

TABLE   XV— CITIES   AND   VILLAGES    TESTING   VISION   AND    HEARING    OF 

<PUPILS  AND  PERSON  DOING  TESTING. 


Person  doing  testing. 


Number 
of  cities  and 

villages 
using  plan 
indicated. 


Teacher 

Physician  or  nurse 
Nothing  done 

Total 


28 
33 
49 


110 


Instructing  the  teacher. — To  a  considerable  extent  the  successful 
carrying  out  of  any  plan  for  health  supervision  of  school  children  de- 
pends on  the  teacher.  It  is  therefore  pertinent  to  note  the  data  pre- 
sented in  the  following  table,  which  indicate  that  in  most  communities 
nothing  is  done  to  inform  the  teachers  about  symptoms  of  communicable 
diseases  or  remediable  defects.  Our  data  show  that  in  practically  all 
cases,  the  instructions  are  given  incidentally,  usually  at  the  appearance 
of  an  epidemic,  rather  than  systematically  from  the  broad  standpoint 
of  preventive  medicine. 

TABLE    XVI— CITIES   AND   VILLAGES    GIVING    HEALTH   INSTRUCTION    TO 

TEACHERS. 


Person  giving  instructions 


Number 

of  cities  and 

villages  in 

each  plan 

indicated. 


Physician. 


XI 


.Ma 

No 


ilendcnt  of  schools  (teachers'  meetings) . .-. 
'     at  out  by  State  Department  of  Health. 


ions. 


Total. 


o 
18 

4 
10 
73 

110 


579 

Medical  and  dental  aid. — In  only  a  small  percentage  of  communi- 
ties are  free  medical  and  dental  aid  given  to  indigent  children.  There 
is  no  common  practice  as  to  who  pays  for  the  free  work ;  in  a  few  cases 
the  school  funds  are  used;  in  others,  school  and  private  funds  together; 
while  in  a  large  nimiber  of  places  the  physicians  and  dentists  give  their 
services  gratis.  The  free  aid  is  usually  given  in  cities  having  hospitals, 
clinics  and  dispensaries,  and  the  majority  of  these  are  located  in  Cook 
County.  Eight  cities  employ  school  dentists  regularl}^,  though  all  on 
a  part-tiine  basis  excepting  Chicago,  which  has  both  part  and  full-time 
employees  in  this  department.  Table  XVII  shows  these  facts  com- 
pletely. 

TABLE    XVII— CITIES    AND    VILLAGES    GIVING    FREE    MEDICAL    AND 
DENTAL  AID  TO  INDIGENT  CHILDREN. 


^  TjTJe  of  aid. 


Number 
of  cities  and 

villages 
giving  type 

of  aid 
indicated. 


Having  both  free  medical  and  dental  aid. 

Having  free  medical  aid  only 

Having  free  dental  aid  only 

Having  neither  free  medical  or  dental  aid. 


19 
27 
20 
63 


Special  schools. — In  two  cities  (Chicago  and  Jacksonville),  open- 
air  school-rooms  are  in  operation.  Thus  it  appears  that  this  modern 
movement  in  school  hygiene  has  received  practically  no  consideration  in 
the  State. 

Chicago  is  the  only  city  operating  classes  for  crippled  children.  At 
present,  such  classes  are  provided  for  in  two  schools. 

So  far  as  our  information  goes  Chicago  and  Eochelle  are  the  only 
cities  operating  classes  for  deaf  and  dumb  children,  while  Chicago  is 
the  only  city  having  classes  for  blind  children,  likewise  for  the  epileptic. 

Instruction  in  hygiene. — That  the  importance  of  teaching  hygiene 
is  recognized  the  nation  over  is  attested  by  the  fact  that  every  state 
makes  provision  for  its  teaching.^^  This  instruction  aims  to  develop 
hygienic  habits  of  living  in  the  present  generation  and  to  lay  the  founda- 
tion for  a  better  order  of  hygiene  in  the  next.  It  will  be  seen  from  Table 
XYIII  that  77,  of  the  110  cities  and  villages  reporting,  teach  hygiene 
through  at  least  the  first  eight  grades,  while  35  carry  it  into  certain 
grades  of  the  high  school.  The  most  common  practice  is  to  begin  the 
instruction  in  thefirst  grade  and  cease  it  at  the  close  of  the  eighth. 
Usually  the  instruction  in  the  first  four  grades  is  oral.  Our  data  show 
that  practically  all  elementary  schools  are  doing  something,  while  little 
is  being  attempted  in  the  high  schools. 

^'  This  is  shown  by  an  examination  of  the  latest  school  codes  of  each  state. 


580 


TABLE   XVIII— GRADES    IN   WHICH   HYGIENE    IS    TAUGHT    IN    110    CITIES 

AND  VILLAGES. 


Grade  limits. 

Number 
of  cities  and 

villages 

using  limits 

indicated. 

1  to  8 

48 

1  to  9 

20 

1  tolO 

6 

1  to  12 

3 

2  to  8 

2 

6  to  8 

5 

4  to  9 

6 

9 

*3 

9  to  12 

*3 

10 

*1 

12 

*2 

Information  incomplete  or  lacking 

11 

Total 

110 

•  These  are  township  high  schools. 

The  amount  of  time  devoted  to  hygiene  varies  widely  as  is  indicated 
by  Table  XIX.  The  average  amount  of  time  spent  increases  in  all  the 
grades,  except  in  the  eighth,  where  there  is  a  slight  decrease  from  the 
seventh.  Many  places,  though  having  the  work,  did  not  state  the  amount 
of  time  given. 

TABLE  XIX— NUMBER   OF  MINUTES   PER  WEEK  GIVEN   TO   HYGIENE   IN 
VARIOUS  ELEMENTARY  GRADES   IN   CITY  AND  VILLAGE   SCHOOLS. 


Number  of  minutes  per  week  by  number  of  cities  and  villages. 

Time 

Grade. 

10-30 

31-50 

51-70 

71-90 

91-110 

111-130 

131-150 

Above 
150. 

aver- 
age. 

1 

2 "■" 

24 
22 
18 
13 
11 
10 
9 
8 

18 
16 
15 
16 
13 
12 
9 
11 

6 
6 
18 
5 
6 
6 
5 
6 

2 
4 
7 

10 
6 
6 

12 
9 

2 
5 
4 
7 
12 
9 
6 
5 

2 
2 
2 
2 
2 
3 
3 
3 

47 

3 ■■ 

4 

3* 

5 
7 
6 
6 

2 

2 
2 
4 
9 
8 

49 

53 

6 

64 

6 

71 

7 ;;"" 

77 

8 

90 

86 

Physical  training.— The  majority  of  schools  appear  to  be  emphasiz- 
ing out-door  exercises,  including  spontaneous  play  and  organized  group 
games;  while  a  smaller  number  rely  chiefly  on  indoor  exercises,  such  as 
calisthenic  exercises,  marches,  drills,  and  simple  forms  of  directed  play. 
In  practically  all  cases  the  work  is  directed  by  the  teacher:  only  a  few 
places  report  special  teachers  for  the  work. 

Although  the  State  has  a  law  requiring  physical  training  in  all 
the  public  schools,  25  schools,  out  of  the  110,  report  that  they  do  nothing. 
m  the  absence  of  definitions  or  standards,  it  is  possible  that  these  schools 
arc  really  doing  more  than  some  of  the  schools  that  report  having  the 
work.  It  may  be  fairly  asked,  what  is  physical  training ?  Many  schools 
appear  to  doubt  whether  they  have  it. 


581 


TABLE  XX— GRADES  IN  WHICH  PHYSICAL  TRAINING  IS  TAUGHT   IN    110 

CITIES  AND  VILLAGES. 


Grade  limits. 


Number 
of  cities  and 

villages 

using  limits 

indicated . 


1  to  8 

Ito   9 

ItolO 

Ito  12 

Ito   4 

Ito   6 

9tol0 

9tol2 

Information  lacking  or  incomplete 
Not  taught 

Total 


38 
6 
6 

17 
1 
2 

*3 

*3 
9 

25 


110 


♦  Township  high  schools. 

The  average  amount  of  time  spent  in  physical  training  is  rela- 
tively constant  for  all  grades,  ranging  from  73  minutes  a  week  in  the 
first  grade  to  83  minutes  in  the  seventh.  There  is  a  slight  increase  from 
grade  to  grade,  except  in  the  eighth,  where  a  slight  decrease  is  seen. 
Table  XXI  shows  these  with  other  facts. 

TABLE  XXI— NUMBER  OF  MINUTES  PER  WEEK  GIVEN  TO  PHYSICAL 
TRAINING  IN  VARIOUS  ELEMENTARY  GRADES  OF  CITY  AND  VILLAGE 
SCHOOLS. 


Number  of  minutes  per  week  by  number  of  cities  and  villages. 

Time 

Grade. 

10-30       31-50 

51-70 

71-90 

91-110 

111-130 

131-150 

Above 
150.- 

aver- 
age. 

1 

8 
9 
7 
6 
5 
5 
4 
4 

13 

11 

11 

10 

9 

8 

8 

8 

9 

9 

8 

9 

11 

11 

11 

11 

8 
8 
10 
12 
12 
16 
15 
14 

11 

10 

10 

10 

11 

9 

9 

8 

7 
8 
8 
7 
5 
6 
.       7 
6 

2 
3 

3 
4 
3 
3 
3 
3 

2 

2 
3 
2 

72 

2 

73 

3 

76 

4 

78 

5 

79 

6 

80 

7 

83 

8 

82 

Coordination  between  physical  training  and  medical  inspection. — 
In  some  half  dozen  cases  coordination  is  reported  between  the  physical 
training  and  medical  inspection  departments.  In  these  instances  it  is 
stated  that  the  physical  training  director  has  a  list  of  pupils  and  the 
results  of  physicians'  findings  so  that  pupils  may  be  given  the  kind  of 
work  they  most  need.  In  no  case  where  the  teacher  gives  the  physical 
training — any  other  practice  is  uncommon — is  any  coordination  be- 
tween the  work  of  the  two  departments  reported. 

Absences  caused  by  sickness. — That  sickness  is  the  major  cause 
of  absence  from  school  is  clearly  indicated  by  Table  XXII.  Practically 
every  superintendent  stated,  however,  that  exact  figures  were  not  avail- 
able, so  he  gave  his  best  estimate.     These  estimates  may  be  considered 


582 


as  fairly  accurate  since  they  agree  in  the  main  with  studies  made  in 
Chicago^^  and  elsewhere.^^  Several  studies  have  indicated  that  there  is 
a  close  correlation  between  illness  loss  and  retardation,  elimination  and 
non-promotion,  and  these  considerations  would  suggest  the  problem  of 
reducing  sickness  to  a  minimum. 

TABLE   XXII— PERCENTAGE   OF  ABSENCE  CAUSED   BY   SICKNESS. 


Percentage  of  absence. 

Nnmber  of 

cities  and  villages  with 

percentage  indicated. 

Element- 
ary. 

High. 

Less  than  20 

3 

5 

8 

9 

30 

20 

4 

20  to  35 

3 

36  to  50 

7 

51  to  65 

4 

66  to  80 

7 

81  to  95 

18 

What  Chicago  is  doing. — Since  Chicago  has  one  of  the  more  effi- 
cient and  thorough-going  departments  of  medical  inspection  in  the 
United  States,  and  undoubtedly  the  best  in  Illinois,  it  seems  worth  while 
to  treat  its  activities  more  fully  than  we  have  been  able  to  do  in  the 
preceding  tabulations  and  discussions.  Officially  the  department  is 
known  as  the  Division  of  Child  Hygiene  of  the  Department  of  Health. 

The  staff  now  consists  of  157  school  physicians,  dentists,  and  oph- 
thalmologists. Of  these  officers  8  are  full-time,  and  149  part-time 
employees.     There  are  120  school  nurses  employed,  all  full-time. 

The  general  method  of  health  supervision  is  as  follows : 

The  department  at  the  opening  of  school  after  vacations  inspects 
all  children.  Schools  are  visited  daily  by  school  physicians  and  nurses,' 
and  all  children  returning  after  an  absence  of  one  day  are  inspected, 
also  children  referred  by  teacher  or  principal.  Cultures  are  made 
from  noses  and  throats  of  children  when  in  homes  that  have  been  ex- 
posed to  diphtheria.  Children  in  homes  exposed  to  other  contagious 
diseases  are  inspected  daily  during  the  incubative  period  of  the  disease. 
Home  calls  are  made  on  absentees  where  there  is  suspicion  of  contagion. 
Physical  examinations  are  made  of  many,  but  of  only  a  minority  of 
children,  and  parents  are  advised  of  defects  found,  with  follow-up  work 
by  the  nurses. 

In  1915,  Chicago  school  physicians  made  87,099  visits  to  schools— 
63,667  to  public  and  25,532  to  parochial  schools,  and  1,128,232  in- 
spections of  children  were  made.^«  Of  these,  962,130  were  preliminary 
inspections  for  contagious  diseases.  In  addition  to  these,  263,762  in- 
spections for  vaccinal  status  were  made. 

Chicaoi^Tf^.^^''^^'"  ^"""^^^   (Bulletin  No.   6)   of  the  Department  of  Health  of 

JJ^peer,  L.  W.,  School  Health  Administration,  pp.  34-52. 

ment  of  H%amVhff^n;^''Vt''l^^^^^  No.   6)    of  the  Depart- 

1Q1K  «o«^f  K     '.       ^^?-     ■'^   ^^  regretted   that   facts   more   recent   than   those   for 
1915  cannot  be  given.     However,  more  recent  data  will  be  avluable  sh5?tly 


583 

In  1915,  70,729  cases  of  contagious  diseases  were  found  and  21,730 
children  were  excluded  from  school  to  safeguard  the  health  of  others. 
In  the  same  year  physical  examinations  were  made  of  79,383  children. 
Of  this  number  37,356  were  found  to  be  defective  and  32,860  were 
advised  to  seek  treatment,  and  also  were  referred  to  the  school  nurses 
for  follow-up  work.  In  1916,  191,225  were  examined.  Of  these  101,237 
were  found  to  be  defective  and  88,014  were  advised  to  seek  medical  treat- 
ment. The  nature  of  the  defects  is  worth  presenting  in  detail,  as  stated 
in  report  for  1915. 

"A  tabulation  of  the  defects  on  35,166  pupils  shows  the  following: 
Malnutrition,  SOI;  anaemia,  2,639;  enlarged  glands,  7,970;  goitre, 
1,556;  nervous  diseases,  340;  cardiac  diseases,  414;  pulmonary  dis- 
eases, 68;  skin  diseases,  701;  orthopedic  defects,  171;  rickets,  372;  de- 
fective vision,  7,837;  other  diseases  of  the  eye,  1,076;  defective  hearing, 
663 ;  discharging  ear,  372 ;  defective  nasal  breathing,  2,603 ;  defective 
palate,  971;  defective  teeth,  22,711;  hypertrophied  tonsils,  11,777; 
adenoids,  4,489;  tonsils  and  adenoids,  4,350;  mentality  poor,  1,196; 
fair,  8,586. 

"During  the  year  263,762  out  of  286,802  pupils  were  examined 
for  their  vaccinal  status  in  432  public  and  parochial  schools;  65,344  re- 
quired   vaccination;    34,824    received    vaccination;    25,727    secured    a 
typical  result.     The  parents  of  30,500  refused  to  sign  consent  cards  for 
vaccination. 

"The  nurses  made  62,945  visits  to  schools,  of  which  53,644  were  to 
public  schools  and  9,301  to  parochial  schools;  775,970  pupils  were  in- 
spected. Of  these  189,506  were  preliminary  inspections  made  at  begin- 
ning of  school  term,  and  337,543  routine  inspections  made  during 
school  sessions.  In  doing  this  work  3,603  suspect  contagious  diseases 
were  found,  99,279  pupils  were  found  needing  attention,  and  2,207  pupils 
that  should  have  special  examination  for  Fresh  Air  Eooms.''^ 

"Through  the  efforts  of  the  nurses  13,214  operations  were  performed, 
divided  as  follows:  Tonsils  and  adenoids,  1,327;  tonsils,  237;  adenoids, 
89;  eyes,  225;  ears,  71;  eye  glasses,  3,939;  teeth,  8,100;  unclassified, 
226." 

Passing  over  the  other  work  of  the  field  nurses,  "school  dressings" 
and  other  branches  of  activity  of  this  interesting  department,  some- 
thing should  be  said  of  the  dental  service  and  the  work  of  the  ophthal- 
mologist. 

"At  the  ten  dental  clinics  10,760  children  were  examined  and 
8,776  were  found  to  have  defective  teeth;  31,616  treatments  were  given; 
28,421  fillings,  85  crown  and  bridge  work  and  23,457  extractions.  This 
was  accomplished  with  2,043  visits  of  dental  surgeons  to  dispensaries. 

"The  ophthalmologist,  who  has  been  on  service  only  from  September 
8,  1915,  to  the  close  of  the  year,  examined  377  children,  giving  them  the 
necessary  treatment  and  refractions.  One  hundred  and  three  children 
were  refracted  and  given  prescriptions;  the  balance,  274,  were  treated 
for  other  conditions  of  the  eyes.  The  budget  provided  a  fund  of  $800 
for  free  spectacles,  but  our  contract  for  this  work  was  not  available  until 
late  in  the  year.  Out  of  this  fund  257  pairs  of  spectacles  were  supplied 
to  the  indigent.     The  cost  of  these  glasses  was  $266.24." 


584 

What  the  rural  schools  are  doing. — Kural  schools  are  even  more  in 
need  of  health  supervision  than  city  and  village  schools.  In  spite  of 
this  need  they  are  neglected. 

The  city  offers  easy  access  to  competent  doctors  and  dentists  and 
often  times  to  free  medical  and  dental  clinics,  but  these  advantages  are 
usually  difficult  to  obtain  in  the  rural  districts.  Moreover,  country 
folks  are  not  so  likely  to  seek  medical  or  dental  aid,  because  they  have 
not  been  educated  to  the  value  of  it.  Contrary  to  common  belief,  there- 
fore, country  children  in  general  are  more  in  need  of  medical  and  dental 
attention  than  their  city  cousins. 

The  Committee  on  Health  Problems  of  the  National  Council  of 
Education  has  made  a  very  careful  estimate  of  the  percentage  of  physi- 
cally defective  who  are  likely  to  be  found  in  any  community.  These 
estimates  are  based  on  a  study  of  the  available  statistics,  and  involve 
several  millions  of  children  from  different  parts  of  the  United  States 
and  other  countries.     They  are  set  forth  in  the  following  table. 

TABLE  XXIII— ESTIMATED  PERCENTAGE  OF  PHYSICAL  DEFECTS  IN  ANY 
COMMUNITY— URBAN   AND    RURAL    CHILDREN.* 


Defects. 


Percentages  of  children 
having  defects  indicated. 


Urban. 

Rural. 

33.5 

49 

16.4 

28.1 

12.5 

23.4 

13.4 

21 

1.3 

4.7 

7.6 

16 

2.7 

6.4 

2.1 

4.2 

.8 

3.5 

1.5 

1.6 

.3 

1.2 

.4 

.7 

.2 

.8 

Teeth  defects 

Tonsils 

Adenoids 

Eye  defects 

Ear  defects 

Malnutrition 

Enlarged  glands.. 
Breathing  defects. 
Spinal  curvature.. 

Anaemia 

Lung  diseases 

Heart  disease 

Mental  defects.... 


t:..*  From  Chart  33  of  the  Committee  on  Health  Problems  of  National  Council  of 
FA"^"°°  ^^^  American  Medical  Association.  Prepared  by  Dr.  Thomas  D.  Wood, 
526  West  120th  Street,  New  York  City,  1918. 

In  order  to  have  a  general  survey  of  health  promotion  work  in  the 
rural  schools,  a  questionnaire  was  sent  to  each  of  the  102  county  superin- 
tendents, with  the  request  for  answers  to  certain  questions  relating  to 
health  work  in  the  schools  of  each  county.  There  were  99  responses  to 
this  inquiry;  the  facts  obtained  are  summarized  in  the  following  table. 
To  show  how  the  rural  child  fares  when  his  opportunities  are  compared 
with  those  open  to  the  city  child,  a  general  summary  comparison  is  made 
of  the  opportunities  of  each. 


585 


TABLE    XXIV— COMPARISON    OF    HEALTH    SUPERVISION    FEATURES    OF 

CITY  AND  RURAL  SCHOOLS  IN  ILLINOIS. 


Features. 


Number  of- 


School  physicians : 

School  nurses 

Health  records  kept 

Sight  and  hearing  tested 

Instructions  to  teachers 

School  dentists 

Free  medical  aid  to  indigents 
Free  dental  aid  to  indigents . 
Ophthalmic  provisions 


City 

Rural 

schools. 

schools. 

31 

None 

54 

♦None 

41 

None 

61 

Probably 

none 

37 

5 

8 

None 

27 

None 

20 

None 

4 

None 

*  The  County  Superintendent  of  Schools,  Cook  County,  has  asked  his  board  for 
5  rural  community  nurses,  but  as  we  go  to  press  the  matter  is  pending. 

Summary  statement. — The  data  presented  in  this  resume  demon- 
strate beyond  question  the  meagre  provision  for  systematic  school  health 
work  in  this  State.  A  few  communities  have  regular  systems  established, 
and  appear  to  be  carrying  out  the  work  conscientiously  and  thoroughly. 
These,  however,  are  the  exception.  The  great  majority  of  the  cities  and 
villages  are  not  attempting  anything  except  physical  training  and  the 
formal  teaching  of  hygiene.  Many  communities,  which  have  the  work, 
appear  to  be  doing  it  in  a  more  or  less  perfunctory  manner,  because  of 
lack  of  stimulus  of  any  standard. 

No  county  reports  its  rural  schools  as  doing  anything  worth  men- 
tioning, except  that  a  few  state  they  are  creating  good  sanitary  con- 
ditions, fumigating  schools,  etc.  Indeed,  practically  all  report  that  they 
are  doing  absolutely  nothing. 

The  facts  of  this  study  undoubtedly  justify  the  concluding  state- 
ment, that,  excepting  instruction  in  physical  training  and  hygiene,  in 
at  least  95  per  cent  of  the  communities  of  the  State  (rural  and  urban), 
nothing  systematic  is  done  to  promote  the  health  of  school  children, 
except  in  time  of  epidemics.  Then,  the  thing  usually  done  (depend- 
ing of  course  on  the  nature  and  prevalence  of  the  disease)  is  to  close  the 
school. 


586 


SPECIAL  REPORT  XIV.     SICKNESS  INSURANCE  IN 

GERMANY. 

(By  Henry  J.  Harris,  Ph.  D.) 


[Note  by  the  Secretary. — The  following  concise  report  on  Sickness  Insurance  m 
Germany  has  been  obtained  from  the  Ohio  Commission  on  Health  Insurance  and  Old 
A«e  Pensions  in  exchange  for  reports  by  Professor  Commons  on  the  Health  Insur- 
ance Movement  in  the  United  States  and  by  Edith  Abbott  on  the  British  Health 
Insurance  System.  Dr.  Harris  took  a  graduate  course  in  Germany.  For  some 
years  he  was  an  expert  in  the  employ  of  the  United  States  Bureau  of  Labor,  aQd 
While  so  employed  translated  the  German  Insurance  Code  of  1911.  He  is  regarded 
as  the  best  American  student  of  the  German  system.  He  is  now  Chief  of  the 
Division  of  Documents,  the  Library  of  Congress.] 

Obligatory  insurance  against  sickness  on  a  national  scale  began  with 
the  law  of  1883,  but  like  most  social  institutions  there  is  prior  to  this 
date  a  lon^  history  of  effort  to  provide  aid  against  distress  due  to  this 
cause.  The  earliest  forms  of  sickness  relief  were  found  in  the  case  of 
seamen,  miners  and  domestic  servants;  the  first  two  of  these,  it  will  be 
noted  are  industries  which  closely  resemble  modern  large  scale  pro- 
duction and  in  which  therefore,  the  employees  had  a  special  claim  upon 
the  employer  because  the  place  where  work  was  carried  on  and  the  con- 
ditions under  which  work  was  done  were  determined  almost  solely  by 
the  employer.  At  the  beginning  of  the  nineteenth  century  many  special 
forms  of  providing  relief  in  case  of  sickness  and  accident  were  in  use; 
tlie  guilds  had  their  sickness  and  burial  funds,  the  miners  had  even  more 
elaborate  arrangements,  while  seamen  had  special  claims  against  their 
employers  in  case  of  disability.  The  movement  took  a  more  definite 
form  in  the  industrial  code  of  Prussia  of  1845,  which  authorized  the 
local  governments  to  make  membership  in  such  a  relief  organization 
compulsory;  in  1849  this  law  was  amended  so  as  to  permit  the  local 
governments  (communes,  towns,  etc.)  to  compel  employers  to  create 
relief  funds  and  to  require  the  employers  to  bear  a  portion  of  the  ex- 
pense. By  this  time  mutual  aid  funds,  somewhat  similar  to  the  British 
friendly  societies,  began  to  develop  and  the  law  of  1869  stimulated  this 
movement.  The  imperial  law  of  1876  encouraged  the  movement  further, 
so  that' by  1880  there  was  a  wide  variety  of  sick  relief  organizations  in 
operation  and  the  i)lan  of  such  insurance  was  familiar  to  most  of  the 
industrial  population. 

It  is  not  easy  to  determine  exactly  the  motives  of  the  German 
government  in  proposing  a  universal  compulsory  system  of  sickness 
insurance  at  this  time.  Bismark  stated  that  the  reason  was  to  secure  a 
means  of  opposing  the  socialist  movement ;  others  state  that  it  was  a  plan 
to  raise  wages  on  a  national  scale  while  others  claimed  that  it  was  a  con- 
sistent part  of  the  state  policy  of 'caring  for  the  inhabitants  in  distress. 
The  proposal  was  introduced  into  the  Reichstag  in  1882  and  became  a 
law  on  June  15,  1883.  Since  that  date  numerous  improvements  and 
exteDsions  in  the  law  have  been  made,  the  most  important  of  which  are 


587 

the  laws  of  1892,  1903  and  1911.  The  first  two  of  these  extended  the 
occupations  and  industries  covered  by  the  insurance,  increased  the  bene- 
fits, allowed  more  freedom  in  movement  from  one  fund  to  another  and 
provided  for  a  secret  ballot  among  the  insured  persons  in  selecting  their 
representatives. 

While  this  movement  was  going  on  in  the  field  of  sickness  insurance, 
similar  progress  was  made  in  providing  compulsory  insurance  against 
industrial  accident  and  against  old  age  and  invadidity.  These  systems 
were  closely  connected  with  the  sickness  system;  in  case  of  industrial 
accident  the  sickness  insurance  cared  for  the  injured  person  for  the  first 
thirteen  weeks,  after  which  the  accident  organizations  assumed  the  care ; 
in  case  an  insured  person  contracted  a  disease  of  long  duration,  the 
sickness  organizations  provided  the  care  for  the  first  thirteen  weeks 
(after  1903,  the  first  twenty-six  weeks)  after  which  the  invalidity 
institutes  took  charge.  Beginning  with  1900  many  plans  were  put 
forward  for  the  consolidation  of  the  three  systems  and  the  simplifi- 
cation of  the  numerous  law^s  on  the  three  subjects.  The  proposal  for  the 
amalgamation  of  the  three  forms  of  insurance  into  one  system  of  carriers 
for  all  three  was  finally  rejected,  but  in  1911  a  general  codification  of 
all  the  laws  on  the  three  forms  of  insurance  was  adopted.  This  code, 
the  imperial  insurance  code  (Eeichsversicherungsordnung)  became  a 
law  on  July  19,  1911  and  the  section  of  it  relating  to  sickness  insur- 
ance came  into  force  on  January  1,  1914. 

The  scope  and  operations  of  the  sickness  insurance  system  up  to 
the  year  1909  have  been  described  at  some  length  in  the  Twenty-Fourth 
Annual  Eeport  of  the  United  States  Commissioner  of  Labor.^  This 
report,  however,  was  written  two  years  before  the  enactment  of  the  code 
of  1911  and  only  mentions  the  draft  of  the  provisions  of  that  act.  In 
the  following  pages  the  description  of  the  sickness  insurance  system  is 
based  on  the  1911  law.  The  outbreak  of  the  war  in  1914,  however,  pre- 
vented the  publication  of  any  data  relating  to  operations  since  January, 
1914 — in  fact  most  of  the  information  available  stops  with  the  year 
1912.  The  statistics  of  operations  given  in  this  summary  statement 
therefore  relate  to  the  period  prior  to  the  time  the  systems  here  described 
came  into  operation.  The  benefits  provided,  however,  are  practically 
unchanged  in  the  new  law  and  most  of  the  changes  relate  to  admin- 
istration, the  addition  of  certain  groups  of  occupations  (such  as  agri- 
cultural labor)  and  a  closer  cooperation  with  the  accident  and  invalidity 
insurance. 

Persons  Included. 

The  persons  included  in  the  compulsory  insurance  under  the  law 
of  1911  are  in  general  those  employed  for  compensation;  persons  em- 
ployed in  supervisory  and  clerical  positions  are  included  only  if  their 
annual  compensation  is  less  than  2,500  marks  ($595).  The  law  specifies 
workmen,  helpers,  journeymen,  apprentices,  servants,  managers  of  estab- 
lishments, clerks,  etc.  in  commercial  establishments  and  in  phannacies, 
stage  and  orchestra  employees,  teachers,  persons  engaged  in  home-work- 

*  "Workmen's  Insurance  and  compensation  systems  in  Europe,"   Twenty-fourth 
Annual  Report  of  the  U.  S.  Commissioner  of  Labor.     Washington,   1911,   2  vol. 


588 

iug  muuiLiies,  persons  employed  in  navigation  not  covered  by  other  laws, 
persons  employed  in  agricultural  work  which  is  subsidiary  to  an  in- 
dustrial establishment  and  to  apprentices.  Employees  of  establishments 
of  or  in  the  service  of  a  government  (national,  state,  local  )are  exempt 
from  the  insurance  only  if  they  are  entitled  to  benefits  approximately 
equal  to  those  of  the  law. 

An  employed  person  automatically  comes  under  the  compulsory 
insurance  provisions  when  his  name  is  placed  on  the  pay-roll  of  an 
establishment.  The  funds  may  not  make  admission  dependent  on  a 
medical  examination  or  establish  an  age-limit. 

Persons  may  voluntarily  join  an  insurance  fund  if  their  annual 
income  is  less  than  2,500  marks  ($595)^  and  if  they  can  be  classed  as; 
(1)  workmen,  helpers,  journeymen,  apprentices  and  servants;  (2) 
members  of  the  family  of  an  employer  who  receive  no  compensation; 
(3)  petty  employers  who  have  either  no  employees  or  not  more  than  two 
employees.  The  funds  may  make  the  right  to  voluntary  insurance  de- 
pendent on  passing  a  medical  examination  and  limit  it  to  persons  be- 
low a  specified  age. 

The  right  to  voluntary  insurance  is  frequently  made  use  of  by 
insured  persons  who  wish  to  give  up  their  employment  for  a  time  in  order 
to  secure  an  extended  rest  period.  Thus  in  Leipzig  the  women  often 
have  themselves  tranferred  to  the  voluntary  class  several  months  be- 
fore confinement  in  order  to  protect  their  health  during  this  time  and 
to  retain  their  rights  to  the  maternity  benefits  at  childbirth. 

Disability  Provided  For. 

The  disability  for  which  the  insurance  provides  benefits  may  be 
either  what  is  usually  understood  as  sickness,  or  it  may  be  due  to  acci- 
dental injury,  including  both  industrial  and  non-industrial  accidents. 
The  sickness  insurance  system  is  therefore  a  system  of  providing  bene- 
fits both  for  sickness  and  for  accidents ;  it  may  be  described  as  a  system 
of  insurance  for  temporary  disability,  with  a  funeral  benefit  for  fatal 
cases. 

The  disability  due  to  industrial  accident  is  cared  for  by  the  sick- 
ness funds  for  a  period  of  thirteen  weeks,  after  which  the  injured  per- 
son is  cared  for  by  the  accident  insurance  system.  Such  cases  also  are 
entitled  to  the  righer  rate  of  cash  benefit  provided  by  the  accident 
system  after  the  fourth  week  of  disability  and  to  certain  other  benefits, 
both  additional  costs  being  defrayed  by  the  accident  insurance.  This 
applies  of  course  only  when  the  patient  is  included  under  both  systems 
of  insurance,  which  is  usually  the  case. 

The  disability  due  to  a  sickness  which  continues  longer  than 
twenty-six  weeks  is  after  that  date  cared  for  by  the  invalidity  insurance 
system,  provided  that  the  patient  is  included  under  both  systems.  Thus 
a  case  of  tuberculosis  receives  care  from  the  sickness  fund  for  twenty- 
six  weeks,  after  which  benefits  are  provided  by  the  invalidity  system 
until  recovery  or  death. 

Normal  childbirth,  which  is  not  technically  sickness,  is  also  pro- 
vided  with  sickness  care,  as  described  below ;  abnormal  childbirth  is, 

•Changed  to  1190  by  order  of  November  22,  1918.     [Secretary's  Note.] 


589 

of   course,   sickness   and   the    illnesses   of   pregnancy   likewise   receive 
benefits. 

Benefits  of  the  System. 

The  benefits  of  the  system  consist  of  medical  care,  cash  benefit, 
maternity  benefit  and  funeral  benefit.  The  insurance  laws  prescribe 
the  minimum  benefits  which  the  funds  must  provide  and  then  specify 
the  permissive  increases  over  these,  as  well  as  certain  other  additional 
benefits  which  may  be  granted  if  the  financial  condition  of  the  fund 
warrants  such  action. 

Cash  benefit. — The  cash  benefits  of  the  system  are  computed  from 
a  basic  wage.  Usually  this  is  the  average  daily  compensation  of  the 
group  of  persons  for  whom  the  fund  has  been  established,  but  may  not 
exceed  five  marks  ($1.19)  per  working  day.  However,  if  the  fund  so 
desires,  it  may  use  a  series  of  wage  classes  (with  six  marks  ($1.43)  as 
the  maximum),  or  may  use  the  actual  earnings  of  the  member,  with 
the  same  maximum. 

The  cash  benefit  consists  of  an  amount  equal  to  one-half  of  the 
basic  wage;  beginning  with  the  fourth  day  of  sickness  it  is  paid  for 
each  working  day  if  the  mernber  is  unable  to  work,  but  if  inability  to 
work  begins  later  than  the  fourth  day,  then  from  the  beginning  of  the 
disability.  This  benefit  is  paid  for  twenty-six  weeks  (in  case  of  acci- 
dent, thirteen  weeks)  from  the  beginning  of  the  sickness,  or  if  the 
payment  begins  at  a  date  later  than  the  fourth  day,  then  from  the  be- 
ginning of  the  payment.  This  limit  of  twenty-six  weeks  is  restricted 
to  any  one  year ;  if  the  same  sickness  occurs  again  in  the  following  year, 
the  fund  may  limit  the  payments  to  thirteen  weeks  in  the  next  twelve 
months,  but  if  it  is  a  different  sickness  then  the  member  is  entitled  to 
another  benefit  period  of  twenty-six  weeks.  The  benefit  is  paid  at  the 
end  of  each  week  of  disability. 

In  case  the  patient  who  is  given  hospital  treatment  as  described 
below  has  dependents,  the  cash  benefit  is  reduced  one-half  and  may  be 
paid  directly '  to  the  dependents.  If  the  funds  so  desire,  they  may 
increase  this  benefit  up  to  the  full  amount  of  the  regular  cash  benefit; 
they  may  also  pay  a  member  half  of  the  regular  cash  benefit  even  if  he 
has  no  dependents. 

The  extension  of  the  cash  benefit  which  the  funds  are  permitted  to 
make  consists  of  increasing  the  amount  of  the  benefit  up  to  three- 
fourths  of  the  basic  wage ;  the  payments  may  be  made  for  Sundays  and 
holidays  and  it  may  be  begun  on  the  first  day  of  sickness. 

If  a  member  i3ecomes  unemployed,  he  retains  his  right  to  benefits 
for  three  weeks,  provided  that  during  the  twelve  months  preceding 
his  unemployment,  he  has  either  been  insured  for  twenty-six  weeks  or 
has  been  a  member  for  six  weeks  iijimediately  prior  to  the  date  of  un- 
employment. 

The  medical  benefit  must  always  be  provided  regardless  of  the  cause 
of  sickness  or  disability,  but  the  funds  are  authorized  to  refuse  the  cash 
benefit,  either  wholly  or  partly,  if  the  member  has  intentionally  caused 
the  disability  or  if  it  was  due  to  disorderly  conduct. 

Medical  benefit. — The  medical  benefit  begins  with  the  first  day  of 
disability  and  continues  (as  a  minimum,  for  twenty-six  weeks  (in  case  of 


590 

accident,  thirteen  weeks).     It  consists  of  physician's  services,  medicines, 
and  such  appliances  as  eyeglasses,  trusses  and  similar  therapeutic  aids. 

In  place  of  these  benefits,  the  fund  may  provide  treatment  and 
maintenance  in  hospital  or  similar  institution  (medical  baths,  etc). 
The  consent  of  the  member  is  necessary  if  the  patient  has  a  household 
of  his  or  her  own,  but  hospital  treatment  may  be  made  compulsory  if 
tlie  nature  of  the  sickness  demands  care  or  treatment  which  cannot  be 
given  in  the  house,  or  if  the  sickness  is  contagious  or  if  the  patient's 
condition  calls  for  continuous  observation.  Hospital  treatment  includes 
transportation  to  and  from  the  institution. 

The  funds  .may,  with  the  consent  of  the  member,  provide  care  and 
attendance  by  nurses  or  other  professional  attendants,  especially  in  cases 
where  hospital  treatment  is  advisable  but  cannot  be  secured.  For  such 
hospital  treatment  or  nurse's  service,  a  reduction  in  the  amount  of  the 
cash  benefit  is  made. 

The  question  of  the  choice  of  physician  has  always  been  a  matter 
of  controversy  in  Germany  as  well  as  in  other  countries.  The  insured 
persons  and  the  doctors  have  generally  advocated  wide  freedom  of  choice 
of  physician  by  the  patient,  while  the  expense  of  such  a  plan  has  al- 
ways led  the  officials  in  charge  of  the  system  to  endeavor  to  concentrate 
the  medical  work  in  as  few  hands  as  possible.  The  plan  usually  adopted 
is  to  make  annual  contracts  with  a  limited  number  of  physicians,  the 
basis  of  compensation  being  either  a  specified  rate  per  member  of  the 
fund  or  a  specified  rate  per  case  treated.  The  competition  among  the 
physicians  for  the  position  of  fund  physician  has  in  the  past  been  bo 
keen  as  to  reduce  the  rate  of  compensation  to  a  very  low  level  and  in  a 
few  cases  the  dissatisfaction  of  the  medical  profession  with  this  ar- 
rangement has  led  to  controversies  with  the  officials  of  the  funds.  To 
meet  the  wishes  of  their  members,  some  funds  have  made  contracts  with 
a  large  number  of  physicians,  allowing  the  patient  a  wide  choice  from 
this  panel.  In  the  city  of  Leipzig  for  instance,  the  number  of  phy- 
sicians under  contract  is  very  large.  The  code  of  1911.  (section  369) 
requires  the  funds  to  give  members  the  right  of  choice  between  at  least 
two  physicians  unless  such  choice  would  cause  a  serious  addition  to  the 
costs.  If  a  fund  is  unable  to  make  contracts  on  a  reasonable  basis,  then 
it  may,  as  a  temporary  measure  and  with  the  approval  of  the  super- 
visory officials,  substitute  a  cash  payment  of  not  more  than  two-thirds 
of  the  regular  cash  benefit  for  the  provision  of  medical  attendance  and 
medicine. 

The  funds  are  given  considerable  latitude  in  regard  to  the  ad- 
ditional benefits  which  they  may  provide  if  they  so  desire.  For  instance, 
the  sick  benefits  may  be  provided  for  a  whole  year;  convalescent  care 
may  be  given  for  the  period  of  one  year  after  the  expiration  of  the 
regular  benefits;  appliances  to  prevent  disfigurement  or  deformity  may 
be  supplied  when  such  apparatus  will  aid  in  restoring  ability  to  \wrk ; 
special  diet  such  as  milk,  eggs,  etc.,  may  be  furnished;  more  extensive 
therapeutic  a])pliances  (artificial  limbs,  etc.,)  may  be  wholly  or  partly 
paid  for;  the  members  of  the  family  of  an  insured  person  may  be 
granted  medical  attendance  and  medicines. 

As  normal  childbirth  is  not  usually  designated  as  sickness,  the  law 
specifically  provides  that  women  who  have  been  members  of  the  funds 


591 

for  at  least  six  months  prior  to  confinement  shall  receive  a  maternity 
benefit  equal  to  the  rate  of  the  cash  benefit  for  eight  weeks,  six  of  which 
must  come  after  childbirth.  It  will  be  noted  that  the  prescribed  benefit 
does  not  include  physician's  attendance,  but  if  the  confinement  is  not 
normal  the  case  is  considered  as  one  of  sickness  and  the  regular  sick- 
ness benefits  then  granted.  If  the  funds  so  desire,  they  may  provide 
medical  attendance. 

In  place  of  these  benefits,  the  funds  may  provide  medical  attend- 
ance, maintenance,  etc.,  in  a  maternity  hospital,  or  provide  attendance 
by  home  nurses,  deducting  for  the  latter  not  more  than  half  the  ma- 
ternity benefit. 

The  funds  are  authorized,  if  they  so  desire,  to  provide  a  pregnancy 
benefit  consisting  of  the  regular  cash  benefit,  for  not  more  than  six 
weeks  prior  to  the  date  of  birth;  they  may  also  provide  the  services  of 
a  midwife  and  of  a  physician. 

The  funds  may  also  provide  a  nursing  benefit  to  insured  mothers 
who  themselves  nurse  their  children,  equal  in  amount  to  not  more  than 
half  the  regular  cash  benefit,  for  a  period  of  twelve  weeks  after  birth. 

Funeral  benefit. — The  prescribed  funeral  benefits  consists  of  a  sum 
equal  to  twenty  times  the  basic  wage.  The  funds  may  increase  this 
sum  up  to  forty  times  the  basic  wage  or  may  use  a  minimum  of  fifty 
marks  ($11.90)  for  this  purpose.  The  funds  may  also  provide  a  funeral 
benefit  of  amounts  smaller  than  the  regular  benefit,  for  persons  who  are 
members  of  the  family  of  an  insured  person. 

The  right  to  the  regular  funeral  benefits  follows  the  same  rule  as 
the  cash  benefit  in  case  of  unemployment. 

Administration  of  the  System. 

The  administration  of  the  system  is  based  on  the  fact  that  the  best 
is  always  obtained  by  having  the  insured  persons  themselves,  in  co- 
operation with  their  employers,  conduct  the  insurance  under  the  super- 
vision of  the  government  authorities.  As  sickness  insurance  requires 
a  close  supervision  of  the  beneficiaries  in  order  to  prevent  malingering, 
this  is  best  secured  by  having  the  members  themselves  perform  it  to  as 
great  a  degree  as  possible.  The  insured  persons  are,  therefore,  organized 
into  small  associations,  called  funds,  which  are  for  the  greater  part 
district  organizations  for  specified  areas,  with  special  organizations  for 
occupations  or  industries  or  establishments  where  such  separation  gives 
some  advantage  either  in  administration  or  segregation  of  the  risk. 
These  funds  cover  the  whole  area  of  the  empire  and  nearly  all  of  the 
wage-earning  population.  At  the  date  of  the  introduction  of  the  in- 
surance there  were  in  operation  a  large  number  of  small  funds  many 
of  which  were  continued  under  the  law  of  1883;  since  that  date  there 
has  been  a  tendency  to  eliminate  the  smaller  funds  and  combine  the 
membership  with  the  larger  organizations.  The  code  of  1911  enforces 
this  elimination  of  the  smaller  funds  by  rather  drastic  provisions. 

Each  fund  must  have  a  constitution;  in  the  first  place  it  is  drawn 
up  by  the  local  authorities  for  the  local  and  the  rural  funds,  after  a 
hearing  of  the  employers  and  of  the  insured  persons ;  in  the  case  of  an 
establishment  fund,  by  the  employer  after  a  hearing  of  the  employees; 
in  the  case  of  a  guild  fund,  by  the  general  meeting  of  the  guild  in  con- 


592 

ference  with  the  journeymen's  committee.  The  constitution  must 
specify  the  name  and  seat  of  the  fund,  the  kind  and  extent  of  the  bene- 
fits, the  amount  of  the  contributions,  the  composition,  rights  and  duties 
of  the  executive  board  and  of  the  so-called  ^'committee"  (a  body  of 
delegates  with  advisory  functions),  arrangement  of  the  budget  and 
report  on  expenditures,  etc.  For  purposes  of  supervision  the  whole 
country  is  divided  into  districts,  whose  areas  correspond  with  the 
political  subdivisions.  The  smallest  districts  are  in  charge  of  the  'local 
insurance  offices;"  above  these  are  the  ^'superior  insurance  offices,^ 
covering  such  areas  as  a  province,  state  or  even  a  group  of  smaller 
states.  The  highest  supervisory  powers  are  vested  in  the  Imperial  In- 
surance Office,  though  a  few  states  reserve  matters  to  be  regulated  by 
their  own  State  Insurance  Office. 

These  bodies  have  the  decision  as  to  details  of  organization,  questions 
as  to  compliance  with  the  law,  the  settlement  of  controversies  between 
funds  or  their  members.  They  are  always  composed  of  government 
officials,  together  with  a  group  of  persons  in  which  the  employers  and 
the  insured  are  equally  represented.  The  representatives  of  these  groups 
serve  without  compensation,  though  their  expenses  are  reimbursed  and 
the  workmen  members  are  paid  for  loss  of  earnings,  while  in  attend- 
ance on  meetings. 

These  bodies  have  jurisdiction  over  the  entire  field  of  sickness, 
accident,  invalidity  and  survivors'   (widows'  and  orphans')   insurance. 

The  carriers  of  the  insurance  are  mutual  organizations  (with  the 
legal  status  of  a  corporation)  of  the  insured  persons.  At  the  time 
of  the  enactment  of  the  law  of  1883  there  were  in  existence  a  variety 
of  mutual  benefit  organizations  which  provided  sickness  and  funeral 
benefits  for  their  members  and  in  a  few  areas  membership  in  these 
organizations  was  made  compulsory  by  law.  Some  of  the  organizations 
were  of  considerable  size  and  many  of  them  had  had  a  long  history  which 
had  developed  a  spirit  somewhat  similiar  to  the  "friendly  society  spirit" 
in  Great  Britain.  It  is  estimated  that  there  were  about  2,000,000 
persons  affiliated  with  such  societies  in  1883.  Because  of  the  attach- 
ment of  the  members  to  their  societies  it  was  deemed  expedient  to  make 
use  of  them  as  insurance  carriers  in  the  new  national  compulsory  system, 
as  was  done  in  the  more  recent  British  system. 

Prior  to  1914,  the  following  types  of  funds  were  in  operation : 

1.  Local  sick  funds  (Ortskrankenkassen)  ; 

2.  Parish  or  communal  sickness  insurance  (Gemeinde-Kranken- 
versicherung) ; 

3.  Establishment  funds   (Betriebskrankenkassen) ; 

4.  Building  trades  funds    (Baukrankenkassen) ; 

5.  Guild  funds    (Innungskrankenkassen) ; 

6.  Mutual  aid  funds   (Hilfskassen) ; 

7.  Miners   funds    (Knappschaftskassen). 

Under  the  code  of  1911,  effective  in  1914,  the  types  of  funds 
enumerated  are: 

1.  Local  funds    (Ortskrankenkassen) ; 

2.  Rural  funds   (Landkrankenkassen) ; 

3.  Establishment  funds    (Betriebskrankenkassen)"; 

4.  Guild  funds  (Innungskrankenkassen). 


593 

Besides  these  four,  this  law  recognizes  the  miners'  fund  and  creates 
a  group  which  it  calls  "substitute  funds/'  The  latter  are  mutual  aid 
funds  mentioned  above.  The  miners'  fund  are  not  changed  by  the  1911 
law,  but  the  mutual  aid  funds  are  subjected  to  much  stricter  control 
with  the  ultimate  plan  of  inducing  them  to  consolidate  with  the  four 
groups  just  listed.  The  communal  sickness  insurance  was  abolished  by 
the  new  code;  the  building  trades  funds  also  were  eliminated  and  their 
members,  always  comparatively  few  in  number,  transferred  to  the  other 
funds.  This  action  was  part  of  the  general  policy  of  reducing  the  types 
of  funds  and  simplifying  the  administration  of  the  insurance.  A  new 
type  of  fund,  the  socalled  "rural"  sick  fund  was  created  as  described 
below. 

The  most  important  of  these  types  of  insurance  carriers  is  the  local 
sick  fund,  which  is  separated  into  two  classes,  the  general  local  fund 
and  the  special  local  fund.  The  former  is  intended  to  be  created  in  each 
local  district,  so  that  the  whole  country  shall  be  covered ;  in  cases  where 
it  would  be  advantageous  to  combine  two  or  more  local  government  dis- 
tricts into  one  fund,  this  is  done.  The  new  class  of  fund,  the  rural  fund 
covers  the  same  area  as  the  general  local  organization  and  where  it  is 
desirable,  a  district  may  have  only  a  general  local  or  rural  fund. 

The  general  local  fund  is  intended  to  include  practically  all  the 
industrial  employees  in  the  area  covered  by  it  who  are  included  in  the 
insurance ;  under  the  conditions  specified  in  the  laAV,  the  insured  persons 
may  join  one  of  the  other  classes  of  funds,  but  if  they  do  not,  then  they 
must  be  included  in  the  general  local  fund.  A  district  may  have  more 
than  one  general  local  fund. 

The  special  local  funds  are  those  which  include  persons  engaged 
in  one  or  more  branches  of  industry  or  kinds  of  establishments,  or  the 
insured  persons  of  one  sex  only.*  If  such  a  fund  was  in  existence  on 
January  1,  1914,  when  the  1911  law  came  into  force,  then  it  was  allowed 
to  continue  operations,  provided  it  met  the  following  conditions :  (1)  it 
had  at  least  250  members;  (2)  its  continuance  did  not  endanger  the 
existence  or  solvency  of  the  general  local  or  rural  funds;  (3)  its  benefits 
were  equal  to  those  of  the  law;  (4)  its  solvency  was  permanently  assured; 
(5)  its  area  was  not  larger  than  that  of  the  general  local  fund.  In 
general,  it  was  the  intent  of  the  1911  law  to  prevent  the  creation  of 
new  special  funds  of  this  class. 

The  rural  funds  are  intended  to  include  persons  employed  in  agri- 
culture, servants,  itinerant  craftsmen,  persons  employed  in  industries 
where  the  work  is  done  in  the  home,  and  their  employees.  The  Federal 
council  may  assign  to  these  funds  certain  other  persons. 

The  establishment  fund  is  a  carrier  created  for  the  employees  of  one 
firm  or  establishment;  it  must  have  at  least  150  members,  though  in  the 
case  of  an  inland  navigation  or  an  agriculture  establishment,  50  persons 
are  sufficient.  It  must  not  be  created  if  it  would  reduce  the  membership 
of  the  general  local  fund  below  1,000  members,  its  benefits  must  be  the 
same  as  those  of  the  fund  used  as  a  standard  and  its  solvency  must  be 
permanently  assured.  A  special  type  of  establishment  fund  must  be 
created  temporarily  for  large  construction  operations. 

—38  H  I 


KP4 

The  guild  sick  fund  is  a  type  inherited  from  the  earlier  guild 
organizations  of  craftsmen;  membership  in  certain  guilds  is  compulsory 
even  at  tlie  present  time.  The  master  workmen  who  are  members  of  a 
guild  may  create  a  fund  for  their  journeymen,  apprentices  and  laborers 
and  these  funds  must  in  general  comply  with  the  same  conditions  as  the 
establishment  funds. 

When  an  insured  person  elects  to  become  a  member  of  a  mutual 
aid  fund,  or  "free"  fund  as  it  is  sometimes  called,  he  must  then  pay  all 
of  the  insurance  contributions.  This  type  of  funds  seems  to  be  grad- 
ually disappearing. 

Finances  of  the  System. 

The  cost  of  the  insurance  is  defrayed  by  contributions  from  the 
insured  persons  and  their  employers,  the  former  with  minor  exceptions 
paying  two-thirds  and  the  latter  one-third  of  the  contributions.  The 
basic  wage  referred  to  above  is  used  in  computing  the  amounts  to  be 
paid.     The  state  bears  the  cost  of  supervision. 

The  law  assumes,  on  the  basis  of  past  experience,  that  contributions 
at  the  rate  of  4%  per  cent  of  the  wages  (3  per  cent  from  the  insured, 
114  per  cent  from  the  employer),  will  be  sufficient  to  cover  the  cost  of 
providing  the  regular  benefits  and  other  permissible  expenditures.  Pro- 
vision is  made,  however,  for  an  increase  in  this  rate  where  it  is  found 
to  be  inadequate.  If  in  the  case  of  a  rural  or  local  sick  fund,  a  rate 
of  6  per  cent  is  still  insufficient,  then  the  local  government  must  pay 
the  amount  necessary  for  the  excess ;  in  the  case  of  the  other  funds,  the 
employer  or  the  guild  must  make  up  the  deficit. 

The  employers  deduct  the  contributions  of  the  insured  persons  from 
the  wages,  add  thereto  the  amount  of  their  own  contributions  and 
forward  the  amount  directly  to  the  sick  fund.  The  members  w^ho  insure 
voluntarily  pay  their  own  contributions,  which  are  the  full  amount, 
without  any  contribution  from  the  employer. 

The  funds  are  required  to  accumulate  a  reserve,  which  must  be 
equal  to  at  least  the  average  annual  expenditure  of  the  preceding  three 
year  period.  The  twentieth  part  of  the  receipts  is  the  minimum  amount 
to  be  added  each  year  until  the  reserve  equals  the  sum  just  stated.  Aside 
from  this  reserve,  the  current  receipts  of  each  year  are  expected  to  cover 
the  expenses  of  each  year. 

The  resources  of  the  funds  may  be  used  only  for  the  payment  of 
benefits,  the  accumulation  of  the  reserve,  administration  expenses  and 
for  the  general  purpose  of  prevention  of  sickness. 

Operations  1886-1912. 

The  average  number  of  persons  insured  during  the  years  given  and 
the  number  of  funds  conducting  the  insurance  are  as  follows  :^ 

-^«iJL'^ilf»if,*^**l^i^?J  .^^^^  ^^^  ^^^  sickness  insurance  system  are  published  in  the 
riufV..  Statiatik  dea  Deutachen  Reicha:     the  figures  in  the  summary  tables 

rKl^J?..^  #  taken  from  volumes  170.  229  and  268.  These  tables  do  not  include 
ShrSVfTT'  ?;  «»!»r^ir,f'"^  Insurance,  which  are  published  annually  in  the  Viertel- 
iSShU  to  «^rini«  flll^  ^^^  ^^HJ,^l'®"^^«^°^s-  In  a  few  of  the  tables  it  has  been 
£2^fl#««iMV  rfl^  n.«*^ir  ^""d  ^V^-o^l?^^'  h^^e  been  taken  from  Vierteljahrshefte 
BUT  Statistik  dea  Deutachen  Reicha,  24  Jahrfang,  1915,  Erster  Heft.  pp.  69-72. 


595 


NUMBER   OF   SICKNESS    INSURANCE    FUNDS   AND   NUMBER   OF    PERSONS 

INSURED,    1885-1913. 


Number  of 
funds. 

Number  of  persons  insured. 

Year. 

Male. 

Female. 

Total. 

1885* 

18,942 
20,568 
22,508 
23, 188 
23,109 
21,659 
21,342 

3,515,275 
5,266,319 
7,313,855 
9,419,027 

9,783,885 
9,262,137 

778,898 
1,313,220 
2,206,908 
3,650,348 
3,835,163 
3,955,568 

4,294,173 

6,579,539 

9,520,763 

13,069,375 

13,619,048 

1890 

1900 

1910 

1911 

1912 

13,217,705 
13, 566, 473 

1913 

i 

*  The  number  of  persons  insured  is  for  December  31. 

To  the  13,217,705  persons  insured  in  the  funds  regulated  by  the 
1911  law  should  be  added  those  included  in  the  miners'  funds.  The 
total  would  then  be  over  14,000,000.  The  total  population  of  Germany 
according  to  the  census  of  December  1,  1910  was  64,925,993 ;  the  insured 
persons,  therefore,  constitute  over  20  per  cent  of  the  total  population. 
The  occupation  census  of  1907  showed  that  approximately  26,000,000 
persons  were  gainfully  employed;  this  number  includes  many  persons 
included  in  special  insurance  arrangements  (government  employees, 
etc.)  Avhich  have  substitutes  for  the  regular  insurance  system,  as  well 
as  persons  with  incomes  above  the  insurance  limit,  persons  in  professions, 
independent  shop-keepers,  tradesmen,  etc.  On  this  basis,  over  50  per 
cent  of  the  population  gainfully  employed  is  insured  and  Professor 
Manes  estimates  that  over  82  per  cent  of  the  wage-earners  are  included. 
The  number  of  funds  in  1911  was  over  23,000;  the  decrease  in  the 
number  of  funds  and  persons  in  1912  was  due  to  the  fact  that  the 
mutual  aid  funds  were  not  included  in  the  returns  after  1911.  This 
fact  should  be  kept  in  mind  in  connection  with  the  following  tables. 

The  distribution  of  the  insured  persons  among  the  various  types  of 
funds  have  been  as  follows: 


PROPORTION    OF    FUNDS    AND     OF    MEMBEllSHIP     IN    THE    DIFFERENT 

CLASSES    1885-1912. 

PER  CENT  OF  TOTAL.  FUXDS  IN  EACH  CLASS. 


Year. 


Com- 
munal in- 
surance. 


Local 

sick 

funds. 


Estab- 
lishment 
funds. 


Building 
funds. 


Guild 
funds. 


Reg- 
istered 
aid  funds. 


State  reg- 
istered 
aid  funds. 


1885 
1890 
1900 
1910 
1911 
1912 
1913 


13.7 
16.7 
14.8 
35.4 
35.5 
37.7 
37.6 


35  7 
40.4 
46.3 
20.5 
20.5 
21.8 
21.9 


29.4 
26.6 
27.0 
34.3 
34.3 
36.2 
36.1 


0.6 
1.0 
1.9 
3.5 
3.6 
4.1 
4.3 


17.0 

12.9 

9.3 

5.5 

5.3 


3.3 

2.2 

.5 

.6 

.6 


Total. 


100 
100 
100 
100 
100 
100 
100 


596 


PROPORTION  OF  FUNDS  AND   OF  MEMBERSHIP   IN  THE   DIFFERENT 

CLASSES  1885-1912 — Concluded. 

PER   CENT   OP   TOTAL    MEMBERSHIP   IN    EACH    CLASS    OF    FUNDS. 


Year. 

Com- 
munal in- 
surance. 

Local 

sick 

funds. 

Estab- 
lishment 
funds. 

Building 
funds. 

Guild 
funds. 

Reg- 
istered 
aid  funds. 

State  reg- 
istered 
aid  funds. 

Total. 

1885 

13.7 
16.7 
14.8 
12.8 
12.5 
13.0 
12.7 

35.7 
40.4 
46.3 
52.4 
53.0 
57.2 
57.1 

29.4 
26.6 
27.0 
25.0 
24.9 
27.0 
27.4 

0.3 
.2 
.2 
.1 
.1 
.1 
.1 

0.6 
1.0 
1.9 
2.3 
2.4 
2.7 
2.7 

17.0 

12.9 

9.3 

7.1 

3.3 

2.2 

.5 

.3 

100 

18Q0 

100 

1900 

100 

1910 

100 

101 1 

100 

1012 

100 

101^ 

100 

J 

AVERAGE 

MEMBERSHIP   OF   EACH    FUND. 

1885 

83.5 
144.8 
176.7 
209.7 
213.5 
216.3 
216.3 

415.6 
675.7 
966.1 
1,441.6 
1,523.1 
1,607.1 
1,654.4 

230.4 
276.9 
339.0 
415.1 
431.8 
459.7 
482.0 

146.0 
266.6 
300.0 
416.6 
448.8 
409.5 
395.9 

111.1 
166.2 
322.6 
369.7 
393.1 
405.3 
406.3 

404.8 
441.4 
586.4 
739.3 
764.6 

303.3 
313.8 
194.0 
265.5 
272.2 

228.7 

1890 

319.9 

1900 

423.0 

1910 

572.1 

1911 

597.9 

1912 

619.2 

1913 

635.7 

The  special  point  of  interest  in  the  preceding  table  is  the  develop- 
ment of  the  local  funds.  In  1913  over  57  per  cent  of  the  membership 
was  included  in  these  and  in  future  the  proportion  will  probably  be  stiU 
larger.  The  average  size  of  the  funds  has  setadily  increased  since  188-5 
and  in  the  case  of  the  local  funds,  has  increased  very  rapidly. 

The  gross  receipts  and  expenditures  of  the  system  were : 

RECEIPTS  AND   EXPENDITURES  OF  THE   SICKNESS   INSURANCE   SYSTEM, 

1885-1912. 


Receipts. 

Expenditures. 

Year. 

• 

Total. 

Per 
member. 

Total. 

Per 
member. 

1885 

%  15,731,882 

27,264,879 

49,889,447 

105,517,320 

116,342,663 

119,430,133 

3.66 
4.14 
5.24 
8.07 
8.54 
9.04 

$  12,529,945 

25,668,444 

47,264,320 

100,347,531 

111,140,260 

114,065,792 

2.92 

1890 

1900 

3.90 

1910 

4.96 

1911 

7.68 
8.16 
8.63 

1912 

1  he  increasing  revenue  and  outlay  per  member  shown  by  this  table 
require  careful  explanation  in  order  that  false  conclusions  may  not  be 
drawn.  Leaving  out  the  sums  carried  to  reserve  which  have  varied, 
the  more  important  factors  giving  rise  to  an  increased  outlay  per  mem- 
ber are  five  in  number.  First  of  all,  cash  benefits  are  based  upon  wages 
and  these  have  substantially  increased,  during  the  period  covered  bv  the 
table,  becondly,  an  increasing  number  of  funds  have  paid  more  than 
the  prescribed  minima.  For  example,  while  in  1910,  88:i  per  cent  were 
still  paying  m  compensation  of  lost  wages  the  minimum  of  50  per  cent, , 
9.8  per  cent  paid  more  than  this  up  to  662/3,  and  2.1  per  cent  still  larger 
percentages  up  to  the  permissible  maximum  of  75.     Thirdly    conva- 


597 

lescent  care  and  other  benefits  already  mentioned  liave  been  added,  and 
more  liberal  medical  treatment  has  been  provided.  Fourthly,  and  very 
important,  the  minimum  number  of  weeks  for  which  benefits  were  to  be 
paid  was  increased  in  1902  from  13  to  26.  And,  fifthly,  in  an  increasii^ 
number  of  cases  the  funds  have  voluntarily  adopted  rules  for  the  ex- 
tension of  benefits  for  more  than  the  minimum  time.  In  1910,  the 
miners  excluded,  there  were  23,188  funds.  While  22,341  of  these  pro- 
vided benefits  for  the  prescribed  26  weeks  onty,  249  extended  them  for 
more  than  2G  up  to  39  weeks,  585  for  more  than  39  up  to  52  weeks,  and 
13  in  some  cases  (convalescent  care)  for  more  than  a  year. 

As  typical  of  the  operations  of  the  system,  the  following  statement 
shows  the  various  items  of  expenditure  for  1912. 

EXPENDITURES  OF  THE  SICKNESS  INSURANCE  SYSTEM,   1912. 


Class  of  expenditures. 


Amount. 


Per  cent. 


Medical  treatment 

Medicines,  etc 

Cash  benefit — 

(a)  For  members 

(b)  For  family  of  members 

Maternity  and  pregnancy  benefits 

Funeral  benefit 

Treatment  in  hospitals,  etc 

Convalescent  care 

Payment  to  others  for  benefits  provided 

Advances  repaid 

Dues,  etc.,  repaid 

Investments  purchased 

Loans  repaid 

Cost  of  administration 

All  other 

Total 


$20,380,725 
13,020,038 

34,466,339 

1,328,490 

1,715,038 

1,888,035 

12,745,733 

73, 179 

1,220,500 

77,785 

114,799 

18,115,508 

1,853,717 

5,140,414 

1,925,492 


17.8 
11.4 

30.1 
1.1 
1.5 
1.6 

11.1 
0.1 
1.1 
0.1 
0.1 

15.8 
1.6 
4.5 
1.7 


$114,065,792 


100.0 


Nearly  a  third  of  the  expenditure  is  for  the  cash  benefit;  medical 
service,  medicines  and  hospital  treatment,  etc.,  together  make  up  over 
40  per  cent  of  the  expenditure.  The  maternity  and  pregnancy  benefits 
formed  only  1.5  per  cent  of  the  total  while  the  cost  of  administration 
by  the  fund  was  4.5  per  cent. 

NUMBER  AND  DURATION  OF  CASES  OF  SICKNESS  FOR  WHICH  BENEFITS 

WERE  PAID,   1885-1912. 


Year. 


Cases  of  sickness. 


Number. 


Average 
number 
per  100 
mem- 
bers.* 


Days  of  sickness. 


Number. 


Average 
number 
per  100 
mem- 
bers.* 


Davs  of  sickness  per  case  for 
which  benefits  w  ere  paid. 


Male. 


Female. 


All 
members. 


1885 
1890 
1900 
1910 
1911 
1912 


1,804,829 

42.0 

2,422,350 

36.8 

3,679,285 

38.6 

5,197,080 

39.8 

5,772,388 

42.4 

5,633,956 

42.6 

25,301,178 

589.2 

14.1 

14.1 

39,176,689 

595.4 

16.0 

17.2 

64,916,827 

681.8 

17.0 

20.1 

104,708,104 

801.2 

18.9 

23.9 

115,128,905 

845.4 

18.7 

23.7 

112,249,064 

849.2 

18.6 

23.7 

14.1 
16.2 
17.6 
20.1 
19.9 
19.9 


*  Computed  on  number  of  members  on  December  31. 


The  cases  of  sickness  and  their  duration  is  given  in  the  preceding 
table.  Attention  should  be  called  to  the  fact  that  the  cases  of  sickness 
include  cases  of  accident.  In  the  Leipzig  Local  Fund,  the  industrial 
accident  cases  formed  about  eight  per  cent  of  the  total. 

The  table  indicates  that  for  every  100  insured  persons,  approxi- 
mately two-fifths  have  received  benefits  during  the  year.  The  days  of 
sickness  for  which  benefits  were  paid  have  come  to  be  nearly  8.5  per 
member — in  other  words  each  member  must  provide  sufficient  income  to 
the  fund  to  pay  8I/2  days  of  benefits.  The  last  column  in  the  table  is 
perhaps  the  one  most  frequently  referred  to.  It  indicates  that  there 
has  been  an  increase  in  the  benefit  payment  for  cases  of  sickness.  The 
usual  reference  to  this  column  fails  to  take  account  of  the  fact  that  it 
refers  to  the  number  of  days  for  which  benefits  were  paid  and  does  not 
mean  the  actual  duration  of  the  case  of  sickness.  Thus  the  law  of 
1902  increased  the  minimum  benefit  period  from  13  to  26  weeks  and 
included  sexual  diseases  in  the  class  entitled  to  benefit.  These  changes 
naturally  affected  the  average  duration  of  a  case  of  sickness.  Thus  in 
1902  the  average  duration  was  18.8  days,  while  in  1904  the  same  figure 
was  19.7  days.  There,  too,  as  already  stated,  provision  has  been  made 
beyond  the  prescribed  period  in  an  increasing  number  of  cases.  It 
will  be  noted,  however,  that  since  1904  the  average  duration  of  a  case 
has  remained  fairly  constant.  It  is,  therefore,  not  a  valid  deduction  to 
infer  that  this  increase  has  been  due  to  malingering. 

ConcliLsion. 

It  is  not  easy  to  appraise  the  value  of  a  system  of  this  magnitude, 
but  the  outstanding  fact  is  that  it  has  been  in  actual  operation  for  more 
than  thirty  years  and  that  the  only  changes  made  in  it  have  been  in  the 
nature  of  extensions.  Like  all  social  institutions,  it  is  not  without  its 
critics,  who  have  contimially  emphasized  the  heavy  cost  to  the  industries 
of  the  country  and  who  have  claimed  that  the  effect  it  has  had  on  the 
wage-earners  has  not  been  beneficial.  Attention  has  also  been  called  to 
the  small  amount  of  the  relief  provided  in  any  one  case. 

The  burden  which  the  system  imposes  on  the  industry  and  on  the 
wage-earner  can  be  roughly  gauged  from  the  usual  maximum  rate  of 
dues,  namely  3  per  cent  of  wages  from  the  insured  and  one-half  of  this 
rate  from  the  employer.  The  industry  has  therefore  as  a  rule  to  add 
not  more  than  II/2  per  cent  to  its  pay-roll  for  sickness  insurance.  The 
charge  in  the  Leipzig  Local  Fund  is  2.7  per  cent  of  wages  to  the  in- 
sured persons.  Obviously  a  more  accurate  method  of  representing  the 
burden  would  be  by  expressing  it  in  terms  of  the  value  of  the  product 
m  certain  industries,  such  as  stone-cutting,  wages  make  up  nearly  90 
per  cent  of  the  cost  of  production,  while  in  others  such  as  textiles,  wages 
make  an  extremely  small  part  of  this  cost.  A  number  of  studies  have 
been  made  on  this  subject,  though  for  present  purposes  they  are  of  little 
assistance  because  they  give  only  the  total  cost  for  all  three  branches  of 
insurance  without  stating  the  figures  for  sickness  separately.  Dawson 
(Social  Insurance  in  Germany)  states  that  the  cost  to  the  association  of 
Colliery  and  Smelting  Works  Owners  of  Upper  Silesia  on  account  of 
sickness  insurance  m  1911,  was  eight  cents  per  ton  of  product.  In 
many  lines  of  industry  the  total  cost  of  all  forms  of  insurance  does  not 


599 

exceed  one  per  cent  of  the  value  of  the  product.  During  the  thirty 
years  of  operation  of  the  insurance  laws,  the  share  of  Germany  in  the 
world^s  exports  has  increased  while  the  statistics  of  the  invalidity  in- 
surance show  that  there  has  been  an  increase  in  the  proportion  of  per- 
sons in  the  higher  wage  classes  and  a  corresponding  decrease  has  occurred 
in  the  proportion  receiving  the  lower  wage  rates. 

The  criticism  that  the  amounts  paid  by  the  insurance  system  are 
small  can  only  be  answered  by  pointing  to  the  cost,  which  is  correspond- 
ingly small. 

Much  has  been  made  of  the  criticism  that  the  insurance  laws  have 
produced  a  national  tendency  to  enlarge  upon  every  trivial  sickness  and 
to  demand  benefits  upon  every  possible  occasion.  It  is  also  a  fact  that 
during  seasons  of  unemployment,  particularly  during  the  winter  months 
in  case  of  the  building  trades,  the  sickness  claims  at  once  increase. 
There  is,  of  course,  considerable  truth  in  these  statements;  a  universal 
system  of  insurance  includes  both  the  honest  and  dishonest  and  the 
latter  make  use  of  opportunities  in  this  field  as  in  others.  As  the  ad- 
ministrative authorities  are  familiar  with  this  tendency  they  take  steps 
to  combat  it  by  having  medical  and  other  inspectors  to  supervise  the 
beneficiaries. 

A  tendency  for  the  system  to  become  more  bureaucratic  is  also  evi- 
dent. It  is  due  in  part  to  the  gradually  increasing  membership  in  each 
fund,  so  that  the  individual  members  no  longer  have  the  same  personal 
interest  in  the  affairs  of  the  organization.  The  British  Departmental 
Committee  on  Sickness  Benefit  Claims  found  the  same  tendency  under 
the  British  law  and  speak  with  regret  of  the  "loss  of  the  old  Friendly 
Society  spirit.^' 

All  of  the  available  evidence,  however,  tends  to  show  that  both  the 
employers  and  the  wage-earners  regard  the  system,  in  spite  of  its  im- 
perfections, as  of  great  value  and  on  the  whole  bear  the  charges  for  it 
willingly.  While  the  Socialist  members  (the  labor  members)  of  the 
Reichstag  voted  against  the  first  sickness  law,  they  have  strongly  sup- 
ported all  subsequent  laws  enacted.  While  the  cost  of  the  three  systems 
of  insurance  makes  a  substantial  sum  each  year,  there  has  never  been 
a   demand  for  their  abolition. 


600 


SPECIAL  REPORT  XV.     HEALTH  INSURANCE  IN   GREAT 

BRITAIN. 

(By  Edith  Abbott,  Ph.  D.) 


[Note  by  the  Secretary. — Many  points  in  the  history  and  operation  of  the 
British  Health  Insurance  Act  have  been  in  dispute.  The  importance  of  the  British 
system  Is  so  p-eat  that  the  Commission  desired  as  accurate  an  account  of  it  as 
possible.  Miss  Abbott  was  secured  to  prepare  a  concise  statement  because  of  her 
standing  in  scientifle  circles  and  because  she  has  made  a  thorough  study  of  British 
social  Jegislatlon.] 

The  National  Insurance  Act  was  introduced  into  Parliament  by 
Mr.  Lloyd  George,  then  Chancellor  of  the  Exchequer  in  Mr.  Asquith's 
cabinet,  on  May  4,  1911.  After  prolonged  debate  and  repeated  changes, 
it  finally  became  a  law  on  December  16,  1911,  and  went  into  operation 
July  15,  1912.  The  Act  was  amended  in  1913  and  again  in  1918 ;  and 
four  special  amendments  affecting  the  men  in  the*  army  and  navy  were 
passed  between  1914  and  1917.  These  four  war  amendments  will  be 
disregarded  for  the  purpose  of  this  discussion  since  they  were  made 
necessary  by  the  abnormal  conditions  of  the  times,  when  a  large  pro- 
portion of  the  insured  male  population  of  the  country  had  left  their 
ordinary  employments  to  serve  with  the  British  forces. 

Health  insurance  had  been  promised  by  the  Liberal  Party  in  1908, 
and  during  the  three  following  years  Mr.  Lloyd  George  and  the  govern- 
ment actuaries  had  been  at  work  formulating  plans  for  a  scheme  that 
would  be  practicable  in  Great  Britain.  At  the  outset  it  was  found  neces- 
sary to  depart  from  the  non-contributory  principle  which  Parliament  had 
adopted  for  Old  Age  Pensions. 

It  is,  perhaps,  the  contributory  feature  of  the  plan  which  has  led 
to  the  charge  that  the  British  Health  Insurance  Act  was  "made  in 
Germany"  and  that  Great  Britain  had  copied  the  German  scheme.  As  a 
matter  of  fact,  this  charge  was  of  no  importance  before  the  war.  So 
different,  indeed,  was  the  English  from  the  German  scheme  that  the 
statement  was  made  in  the  House  during  the  debate  on  the  bill,  that 
"the  Chancellor  of  the  Exchequer,  in  framing  his  industrial  insurance 
scheme,  has  evidently  gone  to  Germany  not  so  much  for  example  as  for 
knowledge  of  what  to  avoid."  The  English  scheme  is  much  more  gener- 
ous and  democratic  than  the  German  measure.  It  is  generous  in  the 
large  contribution  made  by  the  state,  generous  in  its  special  provision 
for  the  low  wage-earner,  generous  in  its  provisions  as  to  arrears,  and 
democratic  in  its  administration. 

2'he  Adoption  of  the  Contributory  System  in  England. 

Health  insurance  in  England  appears  to  have  been  made  contribu- 
tory solely  because  the  government  could  not  see  its  way  to  financing  a 


601 

non-contributory  scheme.  The  Old  Age  Pensions  system,  which  was 
non-contributory,  was  exceedingly  popular ;  but  the  cost  had  risen  to  the 
large  sum  of  thirteen  million  pounds  per  annum  (approximately  sixty- 
three  million  dollars),  and  to  add  the  entire  cost  of  Health  Insurance 
to  the  Budget  was  admitted  to  be  impracticable  even  by  the  leaders  of 
the  Labor  Party.  Tlie  contributory  principle  appears  to  have  been 
accepted  reluctantly,  since  the  Chancellor  and  the  Prime  Minister  were 
both  on  record  as  opposed  to  financing  social  reform  measures  on  a 
contributory  basis.     In  1908,  Mr.  Asquith  had  said  in  the  House : 

"The  German  system  *  *  »  could  not  be  translated  here  for 
one  simple  and  sufficient  reason,  that  it  is  founded  on  the  two  pillars  of 
inquisition  and  compulsion.  Whatever  the  honorable  member  for  Pres- 
ton may  think,  you  cannot  brigade  the  industry,  you  cannot,  if  you 
would,  set  up  and  work  here  the  complicated  and  irritating  machinery 
by  which  in  Germany  the  necessary  funds  for  a  provision  against  sick- 
ness and  old  age  are  extracted  from  the  profits  of  both  employer  and 
employed.'^ 

Mr.  Lloyd  George,  too,  in  speaking  during  the  Old  Age  Pensions 
debate  had  declared  that  he  had  no  use  for  the  terms  "contributory" 
and-  "non-contributory.'^  So  long,  he  said,  as  taxes  were  imposed  upon 
the  commodities  consumed  in  every  family  in  the  land,  every  family 
in  the  land  w^as  actually  contributing  to  the  pension  (or  insurance)  fund. 

"When  a  scheme  is  financed  out  of  public  funds,  it  is  as  much  a 
contributory  scheme  as  a  scheme  which  is  financed  directly  by  means 
of  contributions  arranged  on  the  German  or  any  other  basis.  A  work- 
man who  has  contributed  health  and  strength,  vigor  and  skill,  to  the 
creation  of  wealth  by  which  taxation  is  borne,  had  made  his  contribution 
already  to  the  fund  which  is  to  give  him  a  pension  when  he  is  no  longer 
fit  to  create  that  wealth." 

Nevertheless  in  practice,  Mr.  Asquith  and  Mr.  Lloyd  George  found 
it  necessary  to  adopt  a  contributory  system  when  they  faced  the  necessity 
of  finding  money  to  pay  for  Health  Insurance,  in  addition  to  Old  Age 
Pensions.  A  bitter  attack  on  the  contributory  principle  by  Mr.  Philip 
Snowden^  (Socialist  and  Labor  member)  brought  from  Mr.  Lloyd 
George  the  reply  that  the  theory  that  the  whole  of  the  burden  ought  to 
be  cast  upon  the  state  was  an  intelligible  point  of  view  that  could  be  de- 
fended "except  by  those  responsible  for  raising  the  money.  *  *  * 
You  cannot  raise  taxation  in  this  country  without  exciting  every 
interest." 

In  general  the  Labor  Members  of  the  House  of  Commons  acquiesced 
in  the  necessity  of  contributions,  and  a  specially  convened  Labor  con- 
ference which  met  in  Coronation  Week  (June,  1911)'  supported  a  con- 

*  Mr.  Snowden  (Hansard  Parliamentary  Debates,  Vol.  26,  c.  1393)  said:  "I 
am  opposed  altogether  to  the  principle  of  contributions.  *  *  *.  A  contributory 
scheme  is  costly,  cumbersome  and  irritating  *  ♦  *.  Such  a  contributory  scheme 
•  •  •  is  against  the  tendency  of  all  recent  legislation.  The  practice  of  requiring 
a  direct  contribution  for  social  services  has  been  gradually  abandoned  during  the 
last  thirty  years,  because  it  was  both  expensive  and  ineffective  *  *  *  working 
people  cannot  afford  to  pay  the  contribution  which  is  to  be  expected  from  them 
under  this  bill  *  *  *.  We  began  forty  years  ago  by  imposing  a  direct  contri- 
bution on  the  parents  of  children  to  pay  for  the  education  of  their  children,  and  it 
took  thirty  years  of  agitation  to  get  rid  of  it.  The  principle  of  state  financial  re- 
sponsibility is  embodied  in  nearly  all  recent  legislation — in  the  "Workmen's  Compul- 
sory Insurance  Acts,  in  Public  Health  Acts,  and  even  in  the  old  age  pension  legis- 
lation." 


602 

tributory  scheme  but  objected  to  the  size  of  the  workers'  contribution. 
A  typical  expression  of  Labor  opinion  came  from  Mr.  Barnes,  who  said 
that  he  believed  the  compulsory  deduction  from  wages  was  "theoretically 
unsound,"  and  workmen  have  hitherto  been  very  chary  about  accepting 
deductions  from  wages,  and  rightly  so."  "The  State,"  he  said,  "ought  to 
bear  these  burdens.  But  we  are  willing  to  face  facts."  Mr.  Eamsay 
MacDonald,  Chairman  of  the  Labor  Party,  speaking  in  the  House  of 
Commons  during  the  debate,  cordially  approved  the  bill  and  accepted 
the  contributory  basis  of  the  scheme  as  necessary  and  proper.  "The 
bill  was  welcomed,'-*  he  said,  "very  heartily  and  most  sincerely"  by  the 
Labor  Party,  and  the  proposed  scheme  represented  a  fundamental  change 
in  public  opinion,  "one  of  those  advances  which  one  finds  in  public 
opinion  happening  periodically  about  once  every  century."  On  the 
whole  the  Labor  leaders,  opposed  though  they  might  be  to  the  contribu- 
tory principle,  preferred  health  insurance  with  contributions  from  the 
workers  to  no  insurance  at  all. 

It  is  only  fair,  before  outlining  and  critizing  the  Act,  to  note  that 
Mr.  Lloyd  George  said  more  than  once  in  the  course  of  the  debate  that 
he  was  really  proposing  only  an  initial  measure,  a  beginning  of  a  much- 
needed  social  reform,  which  would  require  finally  much  more  sweeping 
social  changes  than  could  immediately  be  brought  about.  "I  do  not 
pretend,"  lie  said  emphatically,  "that  this  is  a  complete  remedy.  Be- 
fore you  get  a  complete  remedy  for  these  social  ills  you  will  have  to  cut 
in  deeper  *  *  *.  Meantime,"  he  added,  "till  the  advent  of  a  com- 
plete remedy,  this  scheme  will  alleviate  an  immense  mass  of  human 
suffering  *  *  *.  Something  like  15,000,000  people  will  be  insured 
at  any  rate  against  the  acute  distress  which  now  darkens  the  homes  of 
the  workmen  whenever  there  is  sickness  and  unemployment." 

PART  I.   PROVISIONS  OF  THE  HEALTH  INSURANCE  ACT. 

Scope  of  the  Act. 

Health  insurance  is  compulsory  upon  all  persons  in  Great  Britain 
and  Ireland  from  sixteen  to  seventy  years  of  age  who  are  employed  at 
manual  labor  and  upon  all  other  employed  persons  whose  rate  of  remun- 
eration is  not  in  excess  of  £160  ($778.64)  per  annum.  There  are  a  few 
exceptions  such  as  teachers  for  whom  benefits  are  provided  under  a 
superannuation  scheme,  and  certain  public  employees  and  employees 
of  statutory  companies  where  the  terms  of  their  employment  are  such 
as  to  secure  provision  in  respect  of  sickness  and  disablement  benefit 
not  less  favorable  than  those  provided  by  the  Act.  Exemption  from  the 
Act  18  also  provided  for  certain  persons  such  as  those  not  mainly  depend- 
ent upon  their  own  earnings.  But  the  Act  is  wide  in  its  scope.  Home- 
workers  are  included  under  it,  and  even  such  irregularly  employed 
woikors  as  dock-laborers  and  golf-caddies.  On  the  other  hand,  all  persons 
working  on  their  own  account  such  as  small  shop-keepers  and  peddlers, 
who  form  a  largo  class,  are  not  brought  under  the  Act  except  as  vol- 
untary' contributors. 

,.^*'^^  ^^^}^^^  ^^  voluntary  Insurance  for  which  provision  is  madp  nndpr  thf>  Art 
with  certain  limitations.  Is  omitted  from  this  discussion 


The  number  of  persons  insured  in  February,  1914,  was  13,759,400; 
of  this  number  9,682,300  were  men  and  4,077,100  were  women.  Com- 
paring the  number  of  insured  persons  with  the  estimated  population  be- 
tween sixteen  and  seventy  years  of  age,  there  appear  to  have  been  in 
i'^ngland  approximately  57  per  cent  of  the  adult  male  population  insured 
and  22  per  cent  of  the  adult  female  population  insured. 

The  Insurance  Fund. 

It  has  already  been  said  that  the  British  Insurance  Act  is  a  con- 
tributory scheme.  The  fund  from  which  benefits  are  paid  is  derived 
from  joint  contributions  of  the  employers,  the  insured  wage-earners, 
and  the  state.  The  contributions  are  divided  as  follows:  In  the  case 
of  the  men,  the  state  contributes  two-ninths,  the  employers  three-ninths, 
and  the  men  themselves  four-ninths.  In  the  case  of  the  women,  the 
state  contributes  one-fourth  of  the  sum,  and  the  remainder  is  divided 
evenly  between  the  working  woman  and  her  employer.  The  actual  contri- 
butions per  week  are  as  follows:  4:d.  (8  cents)  from  the  employed  man 
and  3 J.  (6  cents)  from  the  employed  woman ^^  the  employer  contributes 
'id.  (6  cents)  in  either  case;  and  the  state  2d.  (4  cents)  in  either  case. 
The  contributions  are  uniform  for  all  grades  of  labor  with  a  single 
exception,  which  will  presently  be  noted.  The  employer  must  pay  a 
contribution  even  for  employees  who  are  themselves  exempt  from  con- 
tributing. This  is  done  in  order  that  exempt  persons  may  not  be 
specially  sought  after  by  employers  to  the  injury  of  other  workers. 
The  German  "'^class  system'^  of  contributions  and  benefits  was  rejected 
on  the  ground  that,  if  these  were  varied  in  accordance  with  variations 
in  wages,  the  lower  paid  wage-earners  would  receive  very  inadequate 
benefits.  Mr.  Lloyd  George,  speaking  in  the  House  of  Commons  in  1911, 
said  that  he  had  not  adopted  the  German  system  because  in  the  lower 
classes  "the  benefits  are  so  small  that  the  workmen  in  Germany  say  they 
prefer  to  resort  to  parish  relief  as  the  benefits  are  much  too  inadequate. 
For  that  reason  we  have  decided  in  favor  of  one  class,  because  if  you 
have  a  scale  which  is  proportionate  *  *  *  ^^  would  certainly  not 
give  them  (the  lowest  class)  a  minimum  allowance  to  keep  their  families 
from  want."     (Hansard  V.  25,  c.  616). 

Tlie  British  Insurance  System  Non-Contributory  for  Persons  Earning 
Low  Wages. 
From  the  beginning  it  was  planned  to  make  special  provision  for 
those  receiving  very  low  wages.  When  Mr.  Lloyd  George  introduced 
his  bill,  he  said  that  the  flat-rate  contribution  would  have  to  be  modified 
for  persons  earning  abnormally  low  wages.  In  such  cases  the  contri- 
bution of  the  insured  person  was  to  be  reduced,  and  the  difference  was 
to  be  paid  not  by  the  state  but  by  the  employer.     In  the  words  of  Mr. 

'In  Ireland  the  normal  weekly  contribution  from  insured  men  is  Zd.  (6  cents) 
a  week  and  from  insured  women  only  2d.  (4  cents).  This  is  due  to  the  fact  that  in 
Ireland  a  free  state  medical  service  has  been  provided  since  the  year  1851,  and 
therefore  it  was  not  necessary  to  provide  medical  benefit  under  the  Act  for  Irish 
contributors.  There  are  in  Ireland  840  dispensary  districts,  in  each  of  which  there 
is  a  "dispensary  doctor"  who  is  the  local  public  health  officer  as  well  as  the  salaried 
public  medical  attendant.  Although  the  doctor  is  supposed  to  attend  only  "poor 
persons,"  as  a  matter  of  fact,  dispensary  tickets  are  given  away  freely  and  are 
used  by  the  shop-keepers  and  small  farming  class  as  well  as  by  weekly  wage- 
earners. 


604 

Lloyd  George,  'If  you  make  the  state  pay  the  difference,  then  it  means 
that  the  employers  who  pay  high  wages  to  their  workmen  will  be  taxed 
for  the  purpose  of  making  up  the  diminished  charge  for  workmen  of 
other  employers  who  are  paying  less  *  *  *.  We  have  come  to  the 
conclusion  that  the  difference  ought  to  be  made  up  by  the  employer  who 
profits  by  cheap  labour,  and  therefore  in  the  lowest  case  (in  the  case 
of  15s.  a  week  and  downwards)  the  employer  will  pay  more  *  *  *. 
Our  scale  of  deduction  for  the  workmen  is  a  uniform  one  with  the  ex- 
ception of  that  descending  scale  when  you  come  to  the  very  lowest  wages 
and  where  you  really  cannot  expect  a  man  to  pay  4:d  a  week."  As  a 
matter  of  fact,  if  was  finally  provided  that  for  those  in  the  very  lowest 
wage  class,  insurance  was  to  be  non-contributory  and  contributions  were 
to  be  reduced  in  other  classes  as  follows: 

Group  1.  Persons  over  21  years  of  age  earning  not  more  than  Is. 
6d.  (37  cents)  a  day. 

Group  2.  Persons  over  21  years  earning  from  Is.  7d.  (39  cents) 
to  2s.  (49  cents)  a  day. 

Group  3.  Persons  over  21  years  earning  from  2s.  Id.  (51  cents)  to 
2s.  6d.  (61  cents)  a  day. 

For  Group  1,  insurance  is  made  non-contributory  so  far  as  the  wage- 
earner  is  concerned.  The  state  contributes  an  extra  weekly  penny  in 
such  cases,  and  the  employer  is  made  to  contribute  an  additional  3d.  for 
the  insurance  of  adult  males  and  an  additional  2d.  for  the  insurance  of 
adult  females  employed  at  such  low  wages.  In  Group  2,  the  wage-earner 
contributes  only  a  penny  weekly,  the  state  contributes  an  extra  penny, 
and  the  employer's  contribution  is  increased  by  2d.  (4  cents)  a  week 
for  men  and  Id.  (2  cents)  a  week  for  w^omen  employed  at  these 
low  rates.  In  Group  3,  there  is  no  extra  contribution  by  the  state,  but 
the  male  wage-earners  in  this  class  have  their  contributions  decreased 
by  one  penny  while  their  employers'  contributions  are  increasing  at  the 
same  rate. 

Machinery  for  Collecting  Contributions. 

The  contributions  of  employers  and  workmen  are  collected  by  means 
of  special  insurance  stamps,  which  can  be  purchased  at  the  post-office. 
Every  employed  person,  man  or  woman,  is  given  a  card ;  and  at  the  end 
of  the  week  the  employer  puts  on  the  man's  card  a  7d.  stamp  represent- 
ing the  4d.  which  he  deducts  from  the  man's  wages  and  his  own  con- 
tribution of  3d.  The  Post-Master  General  turns  over  the  sums  col- 
lected by  the  sale  of  insurance  stamps  to  the  Central  Health  Insurance 
Authority—the  Insurance  Commissioners.  The  card  is  supposed  to 
remain  in  the  hands  of  the  insured  person;  but  a  workingman  may  leave 
his  card  with  his  employer.  Employers  may  arrange  with  the  Com- 
mission for  the  quarterly  stamping  of  the  cards. 

At  the  end  of  each  quarter,  members  of  Approved  Societies  send 
their  cards  to  their  societies.  Each  society  prepares  a  quarterly  re- 
turn for  the  Commission  showing  the  number  and  value  of  the  contri- 
butions on  the  cards  for  which  the  society  claims  credit.  The  societies 
are  required  promptly  to  furnish  memVs  with  new  cards,  and  the 
stamped  cards,  surrendered  to  the  societies,  are  finally  forwarded  to  the 
rommiFJ^ion. 


605 

Benefits. 

The  benefits  conferred  on  insured  contributors  are  as  follows:  (1) 
''Medical  'benefit":  medical  treatment  and  attendance  including  drugs 
and  appliances;  (2)  '^Sanatorium  benefit":  care  and  treatment  when 
suffering  from  tuberculosis  or  other  diseases  for  which  sanatorium  care 
may  be  needed;  (3)  ''Sickness  benefit'':  the  payment  of  a  weekly  cash 
allowance  to  insured  persons  when  "rendered  incapable  of  work  by  some 
specific  disease  or  by  bodily  or  mental  disablement."  The  ordinary 
benefits  payable  in  case  of  incapacity  for  work  are  10s.  ($2.43)  a  week 
for  men  and  7s.  6d.  ($1.83)  a  week  for  women.  Payments  begin  on 
the  fourth  day  after  such  incapacity  and  may  continue  for  a  period  of 
tAventy-six  weeks;  (4)  "Disablement  benefit":  a  cash  payment  of  5s. 
($1.22)  a  week  for  men  and  women  alike,  which  begins  after  the  twenty- 
six  weeks  of  sickness  benefit  have  expired  and  may  continue  up  to  the  age 
of  seventy  years^  when  old  age  pensions  are  payable;  (5)  "Maternity  ben- 
efits":  a  cash  payment  of  30s.  ($7.50)  in  case  of  the  confinement  of  the 
wife  of  an  insured  person  or  of  any  woman  who  is  herself  an  insured 
person. 

Medical  and  sanatorium  benefits  become  available  immediately,  but 
full  benefits  are  withheld  until  a  specified  number  of  payments  has  been 
made  as  follows:  Sickness  benefit  is  payable  after  contributors  have  been 
insured  for  26  weeks  and  have  paid  26  contributions.  Maternity  benefit, 
originally  deferred  for  the  same  period  of  time,  is,  by  the  amending  Act 
of  1918-,  payable  only  to  contributors  who  have  been  insured  for  42 
weeks  and  have  paid  42  contributions.  Disablement  benefit  is  payable 
only  after  104  weeks  of  insurance  and  the  payment  of  104  weekly 
contributions. 

Medical  and  sanatorium  benefits  are  administered  by  the  Insurance 
Committees.  Sickness,  maternity,  and  disablement  benefits  are  ad- 
ministered through  so-called  "Approved  Societies."  For  such  benefits 
Mr.  Lloyd  George  said  he  believed  the  old  Friendly  Societies  of  Great 
Britain  had  "a  great  tradition  behind  them  and  an  accumulation  of  ex- 
perience which  is  very  valuable  when  you  come  to  deal  with  questions 
like  malingering."  However,  not  only  Friendly  Societies  but  trade 
unions,  industrial  insurance  companies,  and  employers'  provident  funds 
may  become  "Approved  Societies." 

Any  surplus  funds  secured  by  a  society  through  economical  admin- 
istration may  be  used  for  additional  benefits;  such  as,  payment  of 
sickness  benefits  before  the  fourth  day  of  incapacity,  medical  attendance 
on  the  dependents  of  a  society  member,  dental  treatment,  or  the  pay- 
ment of  a  superannuation  allowance. 

Arrears. 

The  English  Act  is  liberal  in  the  matter  of  arrears,  for  no  contri- 
butions are  required  during  periods  of  reported  incapacity  for  work, 
and  benefits  are  gradually  reduced  instead  of  being  totally  withdrawn 
when  arrears  accumulate. 

The  provision  of  the  original  Act  dealing  with  arrears  proved 
difficult  of  administration,  and  amendments  dealing  with  this  subject 
were  passed  in  1913  and  1918. 


The  original  Act  provided  that  a  person  could  cancel  the  arrears 
by  paying  his  own  contributions  and  those  of  his  employer  for  the  missing 
weeks,  but  the  Amending  Act  of  1913  made  it  necessary  for  him  to  pay 
only  his  own. 

Under  the  1918  amendment  the  Insurance  Commissioners  may 
make  regulations  providing  for  the  reduction,  postponement,  or  suspen- 
sion of  benefits  (except  medical  or  sanatorium  benefit  which  remain 
available)  for  persons  who  are  in  arrears.  But  in  calculating  arrears 
the  Act  expressly  provides  that  no  account  shall  be  taken  of  arrears 
accruing  (a)  during  any  period  during  when  the  insured  person  was 
incapable  of  work  and  of  which  notice  was  given  within  a  prescribed 
time;  or  (b)  in  the  case  of  an  insured  woman  during  two  weeks  before 
and  four  weeks  after  her  confinement. 

Administration:  Insurance  Commissions  and  Committees. 

Four  different  Health  Insurance  Commissions  were  created  for  the 
purposes  of  separate  administration  in  England,  Wales,  Scotland,  and 
Ireland;  but  a  Joint  Committee  exists  for  the  regulation  of  certain 
common  problems.  Local  administration  is  entrusted  to  local  Insur- 
ance Committees  which  are  organized  in  each  county  and  county  borough 
and  to  the  health  committees  of  county  and  borough  councils. 

These  committees  may  have  from  forty  to  eighty  members,  and 
due  provision  is  made  in  the  Act  for  the  representation  of  the  various 
interests  concerned.  Three-fifths  of  the  membership  of  a  local  com- 
mittee are  appointed  in  accordance  with  regulation  made  by  the  Xational 
Insurance  Committee  and  must  "secure  representation  both  of  the  in- 
sured persons  who  are  members  of  Approved  Societies  and  deposit  con- 
tributors ;"  one-fifth  of  the  membership  is  appointed  by  county  or  county 
borough ;  two  members  represent  the  doctors,  and  one  to  three  members 
(depending  on  the  size  of  the  committee)  must  be  doctors;  and  the  re- 
maining members  are  appointed  by  the  national  commissioners. 

Local  Insurance  Committees  have  the  following  duties:  (1)  Ad- 
ministration of  medical  benefit  for  all  insured  persons;  (2)  adminis- 
tration of  sanatorium  benefit  for  all  insured  persons  and  their  depend- 
ents; (3)  administration  of  sickness,  disablement,  and  maternity  benefits 
for  deposit  contributors;  (4)  furnishing  reports  to  the  National  Insur- 
ance C^ommissioners;  (5)  responsibility  for  dealing  with  the  causes  of 
"excessive  sickness"  in  any  locality. 

Insurance  is  Carried  hy  Approved  Societies. 

Insurance  is  carried  through  "Approved  Societies,"  and  any  society 
may  be  "approved*'  by  the  insurance  commissioners  if  it  satisfies  certain 
conditions,  the  most  important  of  which  are  (1)  that  it  must  not  be  a 
society  carried  on  for  profit;  and  (2)  that  its  affairs  must  be  "subject 
to  the  absolute  control  of  its  members."  All  contributions  are  paid  into 
the  Treasury,  which  in  turn  credits  to  each  societv  the  contributions 
paid  in  respect  to  the  members  of  that  society. 

The  utilization  of  the  societies  in  the  English  scheme  was  believed 
to  be  a  necessary  expedient  in  view  of  their  great  strength.     Mr.  Lloyd 


GOT 

George  estimated''  that  between  six  and  seven  million  people  had  made 
some  kind  of  voluntary  provision  against  sickness  chiefly  through 
Friendly  Societies  before  the  introduction  of  the  compulsory  scheme. 
An  account  of  the  organization  of  Friendly  Societies  for  the  purposes  of 
insurance  and  of  the  effects  of  the  Act  upon  the  work  of  the  societies 
will  be  given  at  a  later  point. 

Deposit  Contributors. 

Approved  Societies  are  entitled  to  reject  any  insured  person  who 
applies  for  membership,  provided  no  applicant  is  rejected  solely  on  the 
ground  of  age.  The  societies  also  have  the  right  to  expel  members. 
Insured  persons  who  are  refused  admission  to  any  society  and  insured 
persons  who  refuse  to  join  a  society  become  "deposit  contributors.'' 
Their  contributions  and  their  employers'  contributions  are  credited  to 
a  special  fund  to  be  called  the  post-office  fund;  and  their  insurance  is 
said  to  be  carried  by  the  post-office,  although  as  a  matter  of  fact  they 
can  hardly  be  said  to  be  "insured"  at  all,  since  they  receive  in  sickness, 
disablement  or  maternity  benefit  only  the  sums  standing  to  their  credit 
in  the  post-office  fund.  They  do,  however,  receive  medical  benefit  and 
sanatorium  benefit.  In  1914  there  were  under  half  a  million  deposit 
contributors. 

Such  are  the  main  provisions  of  the  Act.  The  remaining  portion 
of  this  report  will  deal  with  Health  Insurance  in  Great  Britain  as  it 
has  actual^  worked  out  in  practice. 

PART  II.    HEALTH  INSURANCE  IN  OPERATION. 

The  Act  went  into  operation  and  the  collection  of  funds  began 
July  15,  1912.  Benefits,  however,  were  not  to  be  granted  immediately. 
Insured  persons  were  to  become  eligible  for  a  sanitoria  benefit  im- 
mediately, but  the  more  important  medical,  maternity,  and  sickness 
benefits  were  not  to  be  available  until  January  15,  1913,  and  disable- 
ment benefit,  which  only  followed  sickness  benefit,  could  not  begin  until 
July  15,  1914 

At  the  time  when  the  war  began,  therefore,  the  Act  had  been  in 
force  only  two  years,  and  benefits  had  been  in  process  of  distribution 
for  an  even  shorter  period.  It  is  important  to  keep  this  fact  in  mind, 
for  many  of  the  criticisms  directed  against  the  Act  are  due  to  con- 
ditions that  inevitably  arose  in  connection  with  the  recent  organization 
of  so  vast  and  complicated  a  piece  of  social  machinery.  Necessarily 
many  details  of  organization  were  found  to  be  unsatisfactory  and  changes 
were  inevitable.  The  war  has,  of  course,  caused  serious  delays  in  the 
development  of  improved  methods  of  administration  and  in  the  pro- 
vision of  additional  benefits.  That  the  great  machine  continued  to 
work  smoothly  throughout  the  war  was  e\'idence  of  the  stability  of 
organization  that  had  been  achieved  in  so  short  a  time. 

*  Hansard's  Parliamentary  Debates.  May  4,   1911,  col.   610. 


G08 

Brifish  Doctors  and  ihe  Health  Insurance  Act. 

One  of  the  first  great  problems  that  confronted  the  government 
after  the  passage  of  the  Act  was  the  attitude  of  hostility  adopted  by  the 
Britisli  Medical  Association  toward  the  provision  for  medical  benefit. 

During  the  two  years  from  1909  to  1911,  when  a  Health  Insurance 
Bill  was  known  to  be  in  preparation,  the  British  Medical  Association  had 
been  preparing  for  a  vigorous  defense  of  the  interests  of  the  medical 
profession.  In  June,  1911,  the  Association  had  presented  certain 
demands  (called  the  "six  points")  that  they  wished  incorporated  in  the 
bill.  Certain  of  these  demands,  especially  "free  choice  of  doctor"  and 
administration  of  medical  benefit  by  insurance  committees  instead  of 
by  Friendly  Societies  were  finally  incorporated  in  the  bill.  Other  dis- 
puted points  (e.  g.,  the  question  of  remuneration)  were  left  to  be  decided 
by  the  administrative  authorities. 

In  February,  1912,  the  British  Medical  Association  again  forwarded 
to  the  government  certain  peremptory  demands,  the  most  important  of 
which  related  to  the  question  of  medical  remuneration.  The  govern- 
ment had  proposed  an  annual  capitation  fee  of  4s.  6d.  for  doctors  and 
l.v.  6d.  for  drugs  and  medicine.  The  Association  claimed  a  minimum 
capitation  fee  of  8s.  6d.  for  doctors  not  including  extras  and  medicine. 

In  order  to  determine  what  was  adequate  remuneration,  it  was 
necessary  to  ascertain  "the  amount  per  head  of  the  population  which 
was  ordinarily  received  by  doctors  in  the  course  of  their  private  practice." 
The  books  of  the  doctors  in  five  important  towns  were  examined  by  a 
committee  of  which  Sir  William  Plender  was  chairman.  The  report, 
presented  to  Parliament  July  11,  1912,  showed  that  in  the  areas  ex- 
amined, the  annual  cost  of  visits  and  consultation,  taking  private  and 
contract  practice  together,  was  approximately  4s.  5^.  per  head  of  the 
population  for  consultation,  for  visits,  and  for  drugs.  Various  qualif}^- 
ing  factors  were  urged  by  the  associated  doctors,  but  the  government 
remained  firm  in  holding  the  demands  of  the  Association  to  be  unreason- 
able and  impracticable. 

On  July  19,  1912,  the  British  Medical  Association  broke  off  all 
negotiations  with  the  government,  and  a  "doctors'  strike"  was  practicallv 
on.  The  strike  was  ultimately  broken  by  a  compromise.  On  October 
23,  1912,  the  government  had  announced  some  proposed  grants-in-aid, 
additional  sums  which  Parliament  would  provide  for  medical  benefits. 
This  made  possible  a  capitation  allowance  of  8s.  Qd.  for  drugs  and  medi- 
cine; and  of  this  6s.  Gd.  was  assigned  for  the  payment  of  doctors  on  the 
panel   and  the  remainder  for  drugs,  medicine,  and  appliances. 

On  November  4,  negotiations  with  the  government  were  again 
opened  by  the  British  Medical  Association,  in  part  because  of  the  govern- 
ment 8  new  offer  and  in  part  because  the  doctors  saw  that  their  strike 
was  certain  to  fail.  The  government  had  threatened  the  appointment 
of  a  sufficient  number  of  salaried  doctors  in  all  districts  where  the 
panels  were  not  filled,  and  these  doctors  were  to  be  given  permission  to 
import  a  sufficient  number  of  assistants  for  the  local  work  and  would 
therefore  be  given  a  threatened  monopoly  of  local  practice  in  areas 
where  the  doctors  continued  on  strike.  Doctors  steadily  joined  the 
pane  s ;  and  by  January,  1913,  there  were  nearly  14,000  doctors  on  the 
panels,  and  there  were  very  few  districts  where  panels  could  not  be 


609 

formed.  Thus  ended  the  attempt  on  the  part  of  the  British  Medical 
Association  to  prevent  the  Act  from  coming  into  force.  The  number 
of  doctors  on  the  panels  has  steadily  increased,  as  will  be  seen  from  the 
following  figures  showing  the  strength  of  the  English  panels  as  pub- 
lished in  the  oificial  report  on  the  administration  of  the  Insurance  Act 
for  the  year  preceding  the  outbreak  of  the  war  (1913-1914)  :^ 

strength  of  panels  on  January  15,   1913 13,996 

Strength  of  panels  on  April  14,   1913 15,659 

Strength  of  panels  on  October   13,    1913 15,870 

Strength  of  panels  on  May  31,  1914 16,059 

The  total  increase  in  strength  since  the  commencement  of  medical 
benefit  is  thus  over  2,000. 

The  Panel  System  at  Work. 

Every  insurance  committee  is  required  to  prepare  and  to  publish 
a  list  of  doctors  who  have  agreed  to  attend  and  treat  insured  persons. 
Every  "duly  qualified  medical  practitioner"  has  a  right  to  be  included 
in  the  panel;  and  every  insured  person  is  given  a  free  choice  of  doctors 
subject  to  the  consent  of  the  doctor  selected.  According  to  the  statute, 
medical  benefit  is  defined  as  "medical  treatment  and  attendance,  in- 
cluding the  provision  of  proper  and.  sufficient  medicine,  and  such  medi- 
cal and  surgical  appliances  as  may  be  prescribed  by  the  Insurance 
Commissioners.'^ 

The  statute  provides,  however,  that  "medical  benefit  shall  not  in- 
clude any  right  to  medical  treatment  or  attendance  in  respect  of  a 
confinement."  The  regulations  of  the  Insurance  Commissioners  have 
put  still  further  limitations  upon  the  scope  of  medical  benefit.  Oper- 
ations requiring  surgical  skill  are  not  required  of  panel  practitioners, 
and  X-ray  diagnosis  and  pathological  and  bacteriological  investigations 
are  also  excluded.  Dentistry  is  left  over  as  an  additional  service  to  be 
provided  in  the  future,  and  the  treatment  of  the  eyes  and  ears  is  held  to 
be  specialist  service  not  required  of  the  panel  practitioners.  As  a 
matter  of  fact,  therefore,  medical  benefit  has  up  to  the  present  under 
the  contracts  with  the  doctors  been  held  down  to  the  treatment  that 
does  not  require  the  services  of  a  specialist.  This  is  in  part  the  basis 
of  the  charge  that  the  British  system  does  not  provide  proper  medical 
care  for  insured  persons.  Mr.  Lloyd  George,  however,  had  promised 
the  provision  of  the  services  of  consultative  experts  and  surgeons,  and 
it  is  reasonable  to  suppose  that  the  medical  service  would  have  been 
developed  to  include  these  services  but  for  the  interruption  of  the  war. 

Certain  other  criticisms  of  medical  benefit  under  the  British  Act 
should  be  examined.  Two  drawbacks  to  the  panel  system  that  were 
early  revealed  by  the  English  Act  are  (1)  the  uneven  distribution  of 
doctors  in  proportion  to  the  population;  and  (2)  the  uneven  distri- 
bution of  work  among  such  doctors  as  there  are.  An  investigation  made 
by  the  English  Fabian  Society  in  1913-14  called  attenion  to  the  fact 
that  in  pleasant  suburban  towns,  it  was  not  uncommon  to  find  one 
doctor  for  every  500  persons,  whereas  in  the  industrial  communities 
there  might  not  be  one  doctor  for  every  3,000  people.  Further  the 
Fabian  report  says: 

'  Great   Britain.     Report  for  191S-U   on   the  Administration   of  National  Health 
Insurance  (Cd.  7496),  p.  176. 

—39  H  I 


610 

"Nor  can  we  say  that  we  have  noticed  much  tendency  to  this  geo- 
grapliical  inequality  of  service  being  remedied  by 'an  inrush  of  doctors 
to  the  slums.  There  is,  in  fact,  a  distinct  shortage  of  doctors,  and  this 
is,  in  itself,  militating  against  the  success  of  the  Insurance  Scheme." 

As  regards  the  second  point,  it  has  been  said  that  free  choice  of 
doctors  by  the  insured  population  will  inevitably  lead  to  uneven  lists 
of  patients  among  the  panel  practitioners.  But  the  difficulty  might, 
of  course,  be  remedied  by  limiting  the  number  of  insured  persons  allowed 
to  each  panel  doctor.  This  change  would  probably  be  opposed  by  the 
doctors ;  but  it  appears  to  be  necessary  to  safeguard  the  interests  of  the 
insured  persons,  who,  according  to  Mr.  Sidney  Webb,  have  as  yet  shown 
no  capacity  for  using  their  privilege  of  "free  choice  of  doctor'' .  intelli- 
gently. In  the  words  of  the  Fabian  report  already  referred  to,  the 
insured  contributors  have  "simply  added  their  names  to  the  list,  how- 
ever crowded,  of  the  best-known  practitioners  in  their  neighborhood. 
In  town  after  town  for  which  we  have  the  figures,  about  one-fifth  of  the 
doctors  on  the  panel  are  coping  with  half  of  the  total  of  insured  persons, 
whilst  four-fifths  of  the  doctors  divide  among  them,  in  comparatively 
small  numbers,  the  other  half.'' 

These  points  are  also  discussed  by  the  English  Health  Insurance 
Commissioners  in  their  official  report.  They  report  that  "as  regards 
the  sufficiency  of  the  number  of  panel  doctors  available  for  the  country 
as  a  whole,  there  can  be  no  possible  doubt  *  *  *.  The  average 
number  of  insured  persons  per  panel  doctor  is  only  about  750,  a  number 
for  which  responsibility  can,  except  under  abnormal  conditions,  be 
accepted  by  a  single  doctor  with  the  greatest  ease"  (Report  for  1913-14, 
Cd.  7496,  par.  469). 

As  to  the  actual  distribution  of  insured  persons  among  the  doctors, 
the  Commissioners  say  that  "it  is  natural  to  expect  that  the  forces  of 
competition  would  result  in  the  existence  of  lists  ahove  and  below  the 
average  in  size;  and  properly  so,  since  it  is  right  that  competence 
and  thoroughness  in  attendance  should  be  recognized  and  rew^arded  by 
a  large  practice  and  corresponding  remuneration." 

The  Commissioners  make  the  following  further  statement  as  to  this 
situation. 

"The  early  circumstances  of  medical  benefit  were,  however,  such  as 
to  disturb  for  the  time  being  the  operation  of  the  competitive  forces. 
In  some  districts  doctors  delayed  coming  on  the  panel  at  the  outset, 
with  the  result  that  many  selections  were  made  before  the  panels  were 
complete,  and  no  opportunity  subsequently  arose  for  a  change  of  doctor 
until  the  end  of  the  year.  Nevertheless,  the  actual  position  as  it 
existed  prior  to  the  first  opportunity  for  change  was  far  from  unsatis- 
factory. Taking  the  figures  of  100  Insurance  Committees  of  a  repre- 
sentative character,  it  appeared  that  at  the  end  of  1913  over  50  per  cent 
of  the  panel  practitioners  had  500  or  less  insured  persons  on  their  lists, 
70  per  cent  had  750  or  less,  80  per  cent  had  1,000  or  less,  90  per  cent 
had  1,500  or  less,  while  over  96  per  cent  had  no  more  than  2,000.  While 
the  nnmhor  of  insured  persons  from  whom  a  panel  practitioner  can 
properly  accept  responsibility  will,  of  course,  varv  with  his  personal 
competence  and  the  extent  of  his  private  practice,  lists  of  the  size 
above  mentioned  could  not,  save  in  exceptional  circumstances,  be  deemed 


611 

excessive;  and  as  regards  the  isolated  instances  in  which  doctors'  lists 
greatly  exceed  these  figures,  it  i/5  generally  the  case  that  the  practice 
is  shared  with  a  partner  or  assistant.  There  are  doubtless  cases,  how- 
ever, in  which  a  redistribution  of  panel  patients  could  be  effected  with 
advantage  to  the  patients  themselves  and  the  standard  of  the  service 
afforded.  Eeforms  in  this  respect  are  taking  place,  and  will  continue 
to  do  so,  as  the  insured  population  become  aware,  and  avail  themselves, 
of  their  opportunities  of  changing  their  doctors;  and  the  whole  question 
is  attracting  the  careful  attention  of  Insurance  Committees  and  the 
medical  profession  locally"   (Keport  for  1913-14,  Cd.  7496,  par.  470). 

It  should  not  be  overlooked  that  the  British  panel  system  repre- 
sents a  series  of  concessions  to  the  doctors  and  has  the  advantage  of 
enabling  panel  doctors  to  retain  their  private  practice.  Some  of  the 
difficulties  that  are  encountered  under  the  panel  system  are  due  to  the 
attempts  that  have  been  made  to  preserve  the  conditions  of  private 
practice.  The  relations  between  the  panel  doctor  and  the  insured 
patient  remain  very  much  like  the  old  private  relations  between  doctor 
and  patient.  It  is  inevitable  therefore,  as  the  Health  Commissioners 
have  noted  in  an  official  report,  that  as  regards  the  standard  and  quality 
of  treatment  given  this  must  inevitably  vary  under  a  system  which 
admits  to  the  panel  all  qualified  practitioners  without  selection.  There 
appears  to  have  been  singularly  little  complaint  of  the  relations  be- 
tween panel  doctors  and  their  insured  patients,  and  according  to  the 
last  report  issued  before  the  war  "complaints  are  comparatively  rare  in 
most  districts;  while  reports  from  all  parts  bear  witness  to  an  in- 
creasing spirit  of  mutual  undertsanding.'^ 

There  seems  to  have  been  little  or  no  complaint  as  to  the  arrange- 
ments with  the  druggists  or  as  to  the  quality  of  the  drugs  furnished.  It 
is  interesting  that  a  letter  from  England  dated  April  5,  1913,  published 
in  the  Journal  of  the  American  Medical  Association  (Vol.  60,  p.  1268), 
calls  attention  to  the  decrease  in  the  sale  of  nostrums  and  the  simple 
remedies  stored  by  pharmacists.  The  decrease  was  estimated  at  20 
per  cent  or  more.  In  some  working-class  centers  the  nature  of  the 
pharmacy  business  has  almost  completely  changed.  In  places  where  the 
amount  of  dispensing  had  been  almost  negligible,  60  or  70  perscriptions 
and  even  a  100  in  some  cases  are  dispensed  daily. 

Finally,  as  to  medical  benefit,  it  should  be  said  that  a  newly  organ- 
ized service  with  16,000  doctors  giving  service  to  millions  of  panel 
patients  cannot  work  without  causing  some  dissatisfaction  to  some  of  the 
individuals  concerned.  Moreover,  no  system  can  be  devised  that  will 
serve  14,000,000  people  to  the  entire  and  continued  satisfaction  of  each. 
Some  of  the  criticisms  of  the  service  given  under  the  medical  benefit 
regulations  may  well  be  attributed  to  this  fact. 

Successes  as  well  as  failures  of  the  system  should  be  noted.  The 
Second  Annual  Report  of  the  Insurance  Commissioners  contains  the 
following  encouraging  statement: 

"The  history  of  medical  benefit  since  the  publication  of  the  last 
Report  is  a  record  of  continuous  improvement  in  the  relations  between 
the  medical  profession  and  the  authorities  administering  the  x\cts,  and 
of  steady  progress  and  cooperation,  on  the  part  of  all  concerned  in  the 
work  of  perfecting  the  administrative  fabric,  not  only  by  means  of  the 


612 

elimination  of  defects  revealed  by  experience  or  unavoidably  due  to  the 
circ  11  instances  attending  the  inception  of  the  benefit,  but  also  by  means 
of  the  extension  and  adaptation  of  the  machinery  so  as  to  secure  a  more 
complete  enforcement  of  the  rights  and  duties  already  established" 
(Heport  for  1913-14,  Cd.  7496,  p.  156). 

Significant,  too,  is  the  further  statement  by  the  Commission  that 
"signs  are  not  wanting  that  definite  tendencies  .are  in  operation,  origi- 
nating with  the  medical  profession  themselves  and  fostered  by  the  re- 
sponsible authorities,  to  raise  the  standard  of  the  whole  of  the  industrial 
practice  of  the  country  and  to  enhance  the  value  of  the  insured  service." 

Further  evidence  of  the  steady  progress  that  has  been  made  toward 
improving  the  administration  of  medical  benefit  has  come  more  recently 
from  the  British  Medical  Association.  This  testimony  of  June  1917, 
is  significant  in  view  of  the  recalcitrant  attitude  maintained  by  the 
Association  toward  the  Act  in  its  earlier  stages.  In  an  Interim  Eeport 
on  the  "Future  of  the  Insurance  Acts,"  which  was  based  on  replies  to  a 
questionnaire  widely  distributed  among  the  Branches  and  Divisions  of 
the  British  Medical  Association  and  the  local  Medical  and  Panel  Com- 
mittees, the  "Insurance  Acts  Committee"  of  the  Association  makes  the 
following  statement: 

"On  a  subject  which  five  years  ago  was  the  most  highly  controversial 
that  had  ever  been  before  the  (medical)  profession,  *  *  *  it  is 
found  (i)  that  many  matters  which  at  the  beginning  of  the  controversy 
gave  rise  to  most  apprehension  have  assumed  a  position  of  quite  minor 
importance;  (ii)  that  the  general  system  by  which  the  state  provides 
medical  advice  and  treatment  under  the  insurance  scheme  is  in  the  main 
approved,  and  that  criticisms  have  a  tendency  to  concentrate  on  a  com- 
paratively few  points  which  *  *  *  are,  after  all,  matters  of  detail 
which  ought  to  be  capable  of  adjustment;  (iii)  that  there  is  a  large 
body  of  opinion  in  favor  of  the  extension  of  the  health  insurance  system 
both  to  kinds  of  treatment  not  at  present  provided  for  and  classes  of 
persons  at  present  excluded  therefrom."* 

It  is  of  further  significance  that  the  results  of  the  questionnaire 
were  said  to  reveal  a  remarkable  unanimity  of  opinion  among  the  medi- 
cal profession  supporting  this  changed  point  of  view  toward  the  insur- 
ance system.  The  present  attitude  of  the  British  Medical  Association 
seems  to  be  one  of  approval  of  the  insurance  system  and  of  fear 
that  the  government  in  pressing  forward  its  plans"^  for  school  medical 
services,  maternity  centers  and  tuberculosis  dispensaries  "has  resolved 
to  allow  the  National  Insurance  scheme  to  die  from  inanition,  or  by 
gradual  undermining  in  favour  of  a  system  of  whole  time  state  medical 
officials.''^ 

Approved  Societies  and  the  Inmrance  Act. 

.  Memhership.—Attev  the  passing  of  the  Insurance  Act,  the  old 
Friendly  Societies  and  Trade  Unions  organized  state  sections  of  their 
organizations  which  became  "Approved  Societies"  under  the  law.  New 
Approved  Societies  were  formed  very  hastily,  and  many  of  these  were 
for  special  groups  of  workers  who  had  in  the  past  failed  to  join  such 

*BriHah  Medical  Journah  June  23,  1917,  Supplement    p    687 
..      'Se«  letter  from  the  Insurance  Acts  Committee  of  the  British  Medical  Associa- 
tion to  National  Health  Insurance  Joint  Committee,  British  Medical  Journal,  Supple- 
ment, 1917,  p.  101. 


613 


organizations.  But  vast  numbers  of  workers  who  had  heretofore  been 
uninsured  were  drawn  into  the  new  organizations  formed  by  the  com- 
meicial  insurance  companies.  The  Piudentiai  for  example,  quickly 
formed  six  "Prudential  Approved  Societies/^  which  enrolled  more  than 
three  million  members.  Similarly  the  "National  Amalgamated  Approved 
Society^'  (formed  by  ten  other  commercial  companies)  enrolled  over 
a  million  and  a  half  members,  and  smaller  companies  appear  to  have 
foi-med  similar  "state  sections'^  as  Approved  Societies.  This  activity  of 
the  commercial  companies  was  undoubtedly  not  forseen  by  those  respon- 
sible for  the  Act  and  appears  to  be  undesirable  since  they  are  not  really 
democratically  controlled  as  the  Act  intended  the  Approved  Societies 
to  be. 

The  following  table  shows  for  the  United  Kingdom  the  number  of 
members  (men  and  women)  of  the  .different  types  of  Approved  Societies 
as  published  in  the  report  for  1913-14,  the  last  report  issued  before  the 
outbreak  of  the  war,  when  conditions  were  still  normal. 


Men. 


Women. 


Total. 


Friendly  societies  with  branches 

Other  friendly  societies 

Trade  unions 

Industrial  assurance  companies  and  collecting  societies. 
Employers'  provident  funds 


Total 

Deposit  contributors. 


Total  insured  persons. 


2,468,119 
2,456,747 
1,233,570 
3,115,270 

87, 238 


9,360,944 


665, 358 

931,719 

233,010 

2,173,291 

23,460 


4,026,838 


3,133,477 
3,388,466 
1,466,580 
5,288,561 
110,698 


13,387,782 
472,272 


13,860,054 


Over-insurance. — The  National  Insurance  Act  carries  a  provision 
against  double  insurance.  No  person  can  become  an  insured  person 
under  the  Act,  i.  e.,  with  contributions  from  employer  and  from  the 
state  added  to  his  own,  in  more  than  one  society ;  but  he  may,  of  course, 
be  a  member  of  several  societies  independently  of  the  Act.  It  apnears 
to  be  not  uncommon  for  a  man  to  carry  insurance  through  the  "state 
side''  of  one  society  and  additional  insurance  through  the  private  or 
voluntary  side  of  that  or  another  society.  In  the  old  Friendly  Societies 
the  great  majority  of  the  members  (in  general  about  90  per  cent  or  more) 
continued  their  full  contribution  and  were  insured  both  on  the  "state 
side''  and  the  "voluntary  side."  As  a  result,  insurance  for  a  sum  in 
excess  of  the  normal  wage  of  the  person  insured  is  now  by  no  means  un- 
common. An  insured  person  may  therefore  draw  a  larger  income 
when  he  is  "on  sick  benefit"  than  he  earns  when  at  work. 

Should  over-insurance  be  allowed?  In  considering  this  question 
it  must  not  be  forgotten  that  expenses  are  greater  in  time  of  illness, 
that  special  and  more  expensive  food  is  required,  and  that  more  care  is 
needed.  Nevertheless,  this  argument  applies  only  to  eases  of  genuine 
illness,  and  the  fact  remains  that  a  temptation  to  draw  sick  benefit 
unnecessarily  may  exist  in  cases  where  more  monev  can  be  drawn  in  this 
way  than  by  remaining  in  work. 

Administration  of  Siclcness  Benefit. 

The  greatest  problem  that  arose  in  connection  with  the  adminis- 
ss8n5[DTS   9AISS80X8   ^Bq;   uoT^eSanB  aq;  sbav  ^ijauaq  ssanjfois  jo  uoi;bj^ 


G14 

claims  were  being  made.  Early  in  1913  it  appeared  that  claims  made 
upon  the  Approved  Societies  for  sickness  benefits  were  in  excess  of  the 
estimates  made  by  the  government  actuaries.  In  the  summer  of  iai3, 
therefore,  a  Departmental  Committee  on  Sickness  Benefit  Claims  wsls 
appointed  in  order  to  determine  whether  these  alleged  excessive  claims 
were  due  to  defects  in  the  machinery  provided  for  establishing  claims 
upon  the  sickness  fund,  or  to  "malingering'^  amonff  insured  persons,  or 
to  errors  in  the  acturial  estimates. 

The  machinery  for  establishing  sickness  benefit  claims. — In  consid- 
ering the  possibility  of  defective  administrative  machinery  as  an  explan- 
ation of  excessive  sickness  claims,  it  should  be  pointed  out  that  although 
the  Approved  Societies  are  obliged  to  pay  claims  for  sickness  benefit  as 
prescribed  in  the  Health  Insurance  Act,  difl;erent  societies  may  adopt 
different  methods  for  making  or  proving  such  claims.  Opportunities 
for  differences  in  policy  are  especially  likely  to  arise  as  regards  such 
points  as  the  definition  of  the  term  "inability  to  work ;"  the  questioning 
of  doctors'  certificates  of  incapacity;  the  system  of  visiting  the  sick  in 
their  homes  during  the  period  when  benefits  are  being  paid;  or  the  dis- 
cipline imposed  on  mWbers  receiving  benefits.^ 

The  meaning  of  the  term  "incapacity  for  work''  is  all  important  in 
the  allocation  of  benefits.  Sickness  benefit  in  the  statute  is  defined 
as  "periodical  payments  whilst  rendered  incapable  of  work  by  some 
specific  disease  or  by  bodily  or  mental  disablement."  This  has  not  been 
interpreted  literally  as  complete  incapacity  but  merely  an  incapacity 
rendering  members  "unable  to  follow  their  ordinary  employment." 
The  practice  of  the  societies  is  to  accept  medical  certificates  of  incapacity 
given  by  panel  doctors  as  the  proof  of  a  claim  for  sickness  benefit. 

A  difficult  question  of  policy  is  met  at  the  point.  Shall  the 
officials  of  an  Approved . Society  question  doctors'  certificates? 

The  official  report  on  the  Administration  of  Health  Insurance, 
1913-14,  called  attention  to  the  fact  that  Parliament  had  virtually 
placed  the  safety  of  the  societies  at  the  mercy  of  the  panel  doctors, 
since  the  expenditure  on  sickness  benefit  was  dependent  on  sound  certi- 
fication, and  that  the  doctors  had  not  shown  themselves  worthy  in  all 
cases  of  the  confidence  reposed  in  them.  Similarly  the  Eeport  of  the 
Departmental  Committee  on  Sickness  Benefit  Claims  noted  that  the 
doctors  under  the  Act  adopted  a  new  attitude  toward  the  Friendly 
Society. 

"While  formerly  doctors  were  ready  to  look  after  the  funds,  they 
are  not  now  prepared  to  consider  the  society  at  all  *  *  *.  With 
regard  to  those  doctors  who  are  now  engaged  in  this  kind  of  work  for 
the  first  time,  there  is  reason  to  believe  that  with  some  exceptions  they 
do  not  correctly  apprehend  the  nature  of  their  task,  the  value  to  be  placed 
on  their  certificates,  the  relation  in  which  they  should  stand  to  the 
society  or  their  responsibility  to  the  working  of  the  whole  machine." 
.  <>n  the  other  liand,  the  Friendly  Societies  appear  to  have  changed 
their  earlier  policy  of  cooperation  with  the  doctors  in  passing  on  sick- 
ness claims.  In  the  old  days  the- officials  had  followed  the  practice  of 
notifying  doctors  of  any  suspicious  behavior  on  the  part  of  members  who 

•  These  questions  of  policy  were  dealt  with  at  length  in  the  Revort  of  the  De- 
partmental Committee  on  Sickness  Benefit  Claims.      (Cd    8396)      ^^^""'^  ""^  ^''^  ^^ 


615 

had  been  certified  as  incapable  of  work ;  and  there  was  a  constant  check 
on  the  doctors'  reports,  and  "the  intimate  knowledge  which  they  had 
of  their  fellow-members  and  their  close  relations  with  the  doctor  enabled 
them  to  exercise  a  very  real  and  effective  check  on  the  certificates  re- 
ceived/' Under  the  National  Insurance  Act  the  problem  of  the  societies 
had  grown  more  difficult,  in  part  because  of  the  increase  in  the  size  of 
their  organizations  and  in  part  because  the  new  membership  was  drawn 
from  those  large  sections  of  the  population  who  were  new  to  the  principle 
of  sickness  insurance. 

The  panel  doctors  and  the  societies. — Serious  difficulty  appears  to' 
have  been  caused  by  the  fact  that  the  large  body  of  certifying  doctors 
had  had  no  experience  \vith  Friendly  Society  practice.  Under  the  old 
system,  when  the  medical  man  was  an  officer  of  the  society  dealing  with 
patients  whose  characteristics  both  he  and  the  officials  knew  more  or  less 
intimately,  there  was  less  scope  for  conflicts  of  opinion  as  to  certifii- 
cation  than  under  the  new  system,  when  patient,  doctor,  and  official 
were  comparatively  ignorant  of  and  out  of  close  relationship  with  each 
other. 

For  the  new  difficulties  of  certification,  the  Approved  Societies  were, 
however,  in  large  part  responsible;  the  new  societies  had  not  adopted 
and  the  old  societies  had  often  relaxed  the  policy  of  questioning  the 
certificates,  and  without  the  helpful  scrutiny  of  the  officials  of  the 
society,  the  doctor  was  powerless  to  certificate  and  discharge  satis- 
factorily. This  may  be  illustrated  by  one  of  the  cases  brought  to  the 
attention  of  the  Departmental  Committee  on  Sickness  Benefit  Claims : 

"In  this  case  an  insured  person  who  was  earning  only  225.  a  week 
but  was  insured  for  34s.,  with  a  previous  record  of  obtaining  ten 
weeks'  benefit  a  year,  claimed  sickness  benefit  after  preliminary  inquiry 
to  satisfy  himself  that  he  was  in  benefit  to  the  full  amount.  In  this 
case  the  local  secretarv  and  the  sick  steward  were  both  satisfied  that  the 
man,  who  beguiled  the  tedium  of  his  leisure  by  attending  to  his  pigs, 
'did  not  seem  ill  in  the  least,'  yet  they  professed  themselves  obliged  to 
pay  benefit  because  he  produced  a  certificate  from  a  doctor,  who  accord- 
ing to  belief  entertained  by  the  local  secretary,  'gives  a  certificate  to  any- 
one who  asks  him  for  one.'  Apparently,  no  attempt  was  made  to  com- 
municate to  the  doctor  the  grounds  on  which  the  society's  suspicions  were 
based." 

In  such  cases  it  is  apparent  that  the  doctor  and  the  society  are 
alike  at  fault.  It  is  clear  also  that  the  difficulties  are  largely  due  to  the 
fact  that  the  system  is  new  and  that  the  administrative  machinery  is  not 
yet  satisfactorily  organized.  All  that  is  necessary  is  that  the  officials 
of  Friendly  Societies  revive  their  old  practice  of  utilizing  their  knowl- 
edge of  the  habits  and  the  behavior  of  the  insured  person  as  evidence 
which  must  be  taken  into  consideration  along  with  the  medical  certificate, 
if  necessary  after  consultation  with  the  doctor,  before  a  decision  is  arrived 
at  on  the  question  of  paying  the  claims. 

Excessive  sicJcness  claims  and  the  pi'oblem  of  fraud. — Among  the 
witnesses,  medical  and  others,  who  testified  before  the  Departmental 
Committee  on  Sickness  Claims,  there  was  a  unanimous  agreement  that 


616 

there-  was  no  "appreciable  amount  of  fraud"  in  claiming  sick  benefit ; 
eome  testimony  was  given,  however,  both  by  doctors  and  by  representa- 
tives of  Approved  Societies  showing  that  without  any  deliberate  fraud 
there  was  some  evidence  of  difficulty  "in  getting  an  insured  person  who 
had  once  declared  on  the  funds  to  declare  off,"—  a  kind  of  unwillingness 
on  the  part  of  insured  persons  "to  bring  the  period  of  incapacity  to  an 

The  desire  to  claim  sickness  benefit  during  convalescence  may  be  a 
reasonable  one,  but  the  Committee  found  it  necessary  to  emphasize  the 
fact  that  under  the  terms  of  the  National  Insurance  Act,  sickness  benefit 
was  not  properly  payable  during  convalescence,  nor  was  it  payable  on  the 
ground  that  a  period  of  rest  would  be  "good  for"  the  insured  person. 
Under  the  Act,  sick  benefit  can  be  paid  only  to  meet  loss  of  wages  because 
of  incapacity  for  work  owing  to  sickness  or  mental  or  bodily  disablement. 

Some  testimony  was  offered  to  show  that  persons  were  less  willing 
to  declare  off  the  sick  funds  when  they  had  no  work  to  go  to.  This 
tendency  to  use  or  continue  sick  benefit  as  a  kind  of  unemployed  benefit 
had  been  fostered  in  the  old  Friendly  Society  days,  and  it  was  said  that 
"successive  generations  of  society  officers  have  winked  at  the  practice." 

Excessive  sickness  claims  and  the  novelty  of  insurance. — Excessive 
claims  were  also  said  to  be  due  to  the  novelty  of  insurance.  For  large 
sections  of  the  adult  male  population  and  for  practically  all  gainfully 
employed  women,  the  right  to  draw  "sick  pay"  in  lieu  of  wages  when 
unable  to  work  was  an  entirely  new  experience.  In  the  beginning  the 
situation  was  not  clearly  understood,  and  most  of  the  insured  persons 
knew  only  that  they  were  making  weekly  pa3^ments  of  small  amounts 
in  order  that  they  might  draw  out  weekly  benefits  of  large  amounts. 
Tliere  was  also,  said  the  Committee  Eeport,  "a  certain  amount  of  evi- 
dence of  an  int-ention  to  get  the  most  out  of  the  Act,  pointing  rather 
to  an  overkeenness  of  business  instinct  than  any  attempt  at  dishonest 
practices." 

On  the  whole  therefore,  in  so  far  as  there  were  unnecessary  claims 
for  sick  benefits,  the  Committee  laid  the  blame  chiefly  upon  faulty  ad- 
ministration. "The  claims,"  it  is  said,  "tend  to  excess  in  those  cases  in 
which  the  inexperience  of  the  administrator,  or  his  over-experience  in 
bad  methods  provide  an  inefficient  machine;"  and,  further,  it  is  noted 
that  "a  laxity  on  the  part  of  the  society  leads  inevitably  to  an  excess  of 
claims  on  the  part  of  the  insured  member."  Obviously  and  fortunately, 
such  administrative  faults  are  remedial,  and  the  most  recent  official 
report  on  the  administration  of  Health  Insurance  notes  an  improvement, 
♦luring  the  period  1914-17. 

During  this  period  the  claims  for  sickness  benefit  decreased,  and 
wlnle  special  causes  arising  out  of  the  war  are  held  to  be  largely  re- 
sponsible for  this  decrease  nevertheless  some  part  of  it  is  to  be  attributed 
to  improvements  in  administration  which  should  be  permanent.  The 
statement  of  the  Insurance  Commissioners  on  this  point  is  as  follow^s: 

"While  special  causes  have  produced  much  of  the  improvement  in 
the  claims,  it  cannot  be  doubted  that  administration  has  also  exercised 
an  important  influence.     There  is  good  reason  to  think  that  some  part 


617 

of  the  high  cost  of  sickness  among  women  in  1913  and  1914  was  not 
normal,  but  was  due  to  a  certain  extent  to  the  application  of  inex- 
perienced supervision  to  the  claims  of  a  class  to  whom  any  sickness  in- 
surance was  in  the  nature  of  a  novelty.  Careful  management  should 
do  much  to  prevent  a  recurrence  of  the  high  rate  of  claims  which  pre- 
vailed during  these  years."^ 

Excessive  sickness  claims  and  the  actuarial  estimates. — Excessive 
sickness  claims  might  also,  of  course,  be  attributed  to  errors  in  the 
actuarial  estimates.  The  Act  provides  for  a  fiat-rate  of  contribution, 
but  the  actuarial  estimates  were  based  on  a  general  average  expectation 
of  sickness  for  the  whole  insured  population.  The  actuaries  could  not, 
in  advance,  make  proper  allowance  for  the  fact  that  the  population  was 
not  to  be  insured  as  a  whole  but  was  to  be  divided  into  separate  societies 
in  which  there  would  be  cases  of  the  segregation  of  persons  who  were 
"bad  risks"  from  the  insurance  standpoint.  As  a  matter  of  fact,  Ap- 
proved Societies  differ  greatly  not  only  in  the  type  of  organization 
adopted  but  in  the  character  of  their  membership.  The  large  societies 
contain  fairly  representative  groups  of  the  whole  insured  population. 
Some  societies,  however,  are  exclusively  made  up  of  women  or  of  men. 
In  other  societies  the  membership  is  selected  on  some  special  basis  such 
as  a  common  occupation,  residence  in  a  particular  locality,  church  mem- 
bership, or  the  practice  of  total  abstinence.  Persons  in  trades  that  are 
hazardous  and  likely  to  produce  sickness  will,  if  associated  in  a  single 
society,  bring  a  high  sickness  rate  to  that  society. 

It  is  clear,  therefore,  that  when  a  society  exceeds  the  actuaries' 
estimate  of  the  expected  sickness  rate,  this  may  be  due  to  the  fact  that  the 
membership  contains  "an  abnormal  proportion  of  lives  of  a  particular 
type  exposed  to  a  sickness  risk  in  excess  of  the  general  sickness  risk  of 
the  whole  population." 

On  the  whole,  it  appeared  that  as  regards  men  and  even  as  regards 
women,  the  actuarial  provision  had  been  adequate  but  the  sickness  claims 
of  married  women  had  been  in  excess  of  the  actuarial  provision.  But 
the  experience  of  different  societies  ■  inevitably  differed  and  differed 
widely.  In  some,  the  claims  greatly  exceeded  the  actuarial  estimates, 
and  in  others  thev  were  well  within  the  actuarial  allowance. 

These  difficulties  were  inevitable  under  the  democratic  British 
system,  which  recognized  the  great  insurance  organizations  that  had 
been  built  up  by  the  people  and  gave  to  the  insured  free  choice  of  carrier. 
Did  Mr.  Lloyd  George  commit  a  grave  error  in  utilizing  Approved 
Societies  as  insurance  carriers?  Can  administration  by  independent 
Approved  Societies  be  made  sound  and  efficient?  Already  steps  have 
been  taken  to  remedy  the  difficulties  caused  by  the  segregation  of  risks, 
but  the  principle  is  apparently  not  to  be  changed.  A  Departmental 
Committee  on  Approved  Society  Finance  and  Administration  was  ap- 
pointed in  January,  1916,^*^  and  this  Committee  emphasized  the  fact 
that  a  flat-rate  of  contribution  under  conditions  permitting  the  segre- 

'  Great  Britain.  Report  on  Adtninistration  of  National  Health  Insurance,  1914- 
17   (Cd.  8890),  p.  12. 

^'^  Interim  Report  of  the  Committee  (Cd.  8251),  May,  1916;  Further  Report 
(Cd.  8396),  October.  1916;  Final  Report   (Cd.  8451),  December.  1916. 


618 

gation  of  insured  persons  "into  societies  of  distinctive  occupational 
hazard"  had  certain  defects.  The  Committee  recommended,  however, 
that  these  defects  should  be  remedied  not  by  the  abolition  of  Approved 
Society  Administration  but  by  additional  exchequer  grants  toward  a 
special  risks  fund.  The  National  Insurance  Amendment  Act  of  1918 
has  met  the  situation  by  the  creation,  with  the  aid  of  special  Parlia- 
mentary grants,  of  a  Central  Fund  and  a  Women's  Equalization  Fund 
to  protect  the  societies  in  which  an  abnormal  rate  of  sickness  prevails. 

Effect  of  the  insurance  act  on  friendly  societies. — Will  the  attempt 
to  administer  the  Insurance  Act  injure  the  Friendly  Societies  instead 
of  strengthening  them,  is  another  question  that  may  be  raised  in 
connection  with  the  Approved  Society  problem.  The  testimony  of  work- 
ing-class leaders  seems  to  be  that  there  is  grave  danger  that  the  Act  may 
destroy  what  was  most  valuable  in  the  old  Friendly  Societies.  Testimony 
before  the  Departmental  Committee  on  Sickness  Benefit  Claims  was  to 
the  effect  that  "as  the  various  organizations  grew,  the  intimate  personal 
cooperation  on  which  they  were  based  tended  to  become  weaker.''  It  was 
said  that  the  sentiment  on  which  Friendly  Societies  were  built  was  a 
"dying  spirit."  "There  has  been  a  tendency  for  what  was  originally 
the  expression  of  a  bond  of  good  fellowship  and  a  desire  to  help  one 
another  to  pass  to  some  extent  to  a  matter  of  mere  business.  The  active 
members  have  been  fewer  in  numbers;  the  social  side  has  not  been  so 
prominent  as  fonnerly."  A  working-class  leader  who  was  a  member 
of  the  Committee  on  Sickness  Benefit  Claims  said :  ^^The  administration 
of  a  compulsory  state  insurance  is  a  burden,  and  not  a  help,  to  Friendly 
Societies  and  Trade  Unions.  The  energies  of  these  democratic  insti- 
tutions are  strained  to  the  breaking-point  and  the  time  of  many  of 
their  ablest  officials  is  spent  on  matters  foreign  to  their  true  aims" 
(Cd,  7687,  p.  85). 

It  is  apparently  difficult  to  find  a  way  of  preserving  local  pride  and 
interest  with  the  centralized  control  and  supervision  necessary  to  effi- 
cient management.  Strengthening  the  central  government  is  likely 
to  destroy  local  enthusiasms  and  to  produce  local  ignorance  and  indiffer- 
ence, "the  decay  of  local  spirit,  the  carelessness  of  the  individual  as 
regards  the  prosperity  of  his  society,  the  dehumanizing  of  the  whole 
machine." 

The  hreakdomn  of  democratic  control. — ^In  the  opinion  of  some 
working-class  representatives  the-theory  of  democratic  control  upon  which 
the  administration  of  the  Act  by  large  numbers  of  independent  Approved 
Societies  was  based  has  broken  down.  This  plan  wfes  originally  adopted 
in  order  to  meet  the  wishes  of  the  working  classes,  but  their  opinion 
seems  to  be  that  it  has  not  been  wholly  successful.  One  of  their  repre- 
sentatives said,  for  example,  in  testifying  before  a  Parliamentary  Com- 
mittee : 

"In  theory,  this  plan  of  administration  was  excellent.  It  was  hoped 
by  this  method  to  secure  democratic  self-government  by  insured  persons 
of  insured  persons.  The  funds  were  to  be  protected  bv  identitv  of 
interest  and  the  extension  of  the  old  Friendly  Society  snirit  into  State 
Insurance.  To  secure  those  advantages  a  contributorV  scheme  was 
reluctantly  accepted  by  a  majority  of  the  working-class  representatives. 


619 

For  these  advantages  economy,  simplicity,  uniformity  of  management, 
and  the  pooling  of  risks  over  the  whole  community  were  sacrificed."^^ 
In  practice,  however,  the  ideals  of  democratic  government  and 
absolute  control  by  members  of  their  own  affairs  have  frequently  been 
non-existent.  In  the  large  industrial  insurance  companies  which  hastily 
secured  the  membership  of  more  than  a  third  of  all  insured  persons,  the 
members  cannot  be  said  to  have  any  effective  control  over  the  organi- 
zation ;  and  in  the  old  Friendlv  Societies  the  old  forms  of  local  self- 
government  seem  to  have  been  giving  place  more  and  more  to  centralized 
systems  of  eontrol.  Eadical  changes  in  administration  may  yet  prove 
to  be  necessary.  Working-class  leaders  fear  on  the  one  hand  the  dis- 
organizing effects  of  the  Act  upon  the  workingmen's  societies  and  resent 
on  the  other  hand  the  undemocratic  methods  of  the  commercial  in- 
surance companies. 

The  Administration  of  Sanatoriwm  Benefit. 

Sanatorium  benefit  is  largely  a  tuberculosis  benefit,  and  on  the 
administrative  side,  it  is  a  question  of  cooperation  with  the  local  author- 
ities in  providing  the  necessary  dispensaries  and  sanatoria. 

A  special  Departmental  Committee  on  Tuberculosis  was  appointed 
in  February,  191.2,  and  the  two  reports  issued  (April,  1912,  Cd.  6164, 
and  March,  1913,  Cd.  6641)  recommended  the  adoption  of  comprehensive 
schemes  for  providing  adequate  care  for  the  w^iole  population  through 
the  cooperation  of  Insurance  Committees  with  the  Public  Health  authori- 
ties and  local  government  agencies  such  as  the  County  Councils.  The 
government  therefore  undertook  the  making  of  grants-in-aid  not  to  the 
Insurance  Committees  but  to  the  local  authorities.  That  is,  in  place 
of  a  scheme  for  insured  persons  and  their  dependents  organized  by  In- 
surance Committees  and  financed  out  of  their  income  supplemented  by 
contributions  from  the  Exchequer  and  the  rates,  the  plan  came  to  be, 
in  the  words  of  the  Annual  Eeport  for  1913-14,  ^^comprehensive  schemes 
for  whole  areas  organized  by  the  local  authority  and  financed  partly  out 
of  rates  and  partly  by  the  aid  of  contributions  from  Insurance  Com- 
mittees and  the  Exchequer. 

Before  the  outbreak  of  the  war  more  than  a  hundred  Councils  had 
submitted  to  the  Local  Government  Board,  schemes  looking  toward  com- 
prehensive treatment,  including  the  provision  of  dispensaries,  sanatoria, 
and  hospitals,  both  for  insured  and  uninsured  members  of  the  popu- 
lation. In  spite  of  the  delays  and  interruptions  caused  by  the  war,  the 
tuberculosis  schemes  have  been  carried  forward.  The  number  of  tubercu- 
losis dispensaries  had  increased,  for  example,  from  255  in  June,  1914, 
to  370  by  August,  1917;  the  number  of  beds  in  approved  residential 
institutions  had  increased,  from  9,200  in  June,  1914,  to  11,700  in 
Au2^st,  1917. 

Criticisms  of  the  inadequacy  of  provision  for  tuberculosis  appear  to 
be  very  general  in  spite  of  the  progress  that  has  been  made.  Indeed, 
in  view  of  the  magnitude  of  the  problem,  it  could  not  be  expected  to  be 
otherwise.     The  Insurance  Acts  Committee  of  the  British  Medical  Asso- 


"  Great   Britain.     Report   of  the   Departmental   Committee  on  Sickness  Benefit 
Clai7ns   (Cd.   7687),  p.  83. 


620 

ciation  reported  general  agreement  to  the  effect  "that  the  public  funds 
provided  are  not  sutticient  to  enable  proper  provision  to  be  made  lor  all 
tubercular  persons  needing  help  to  obtain  suitable  treatment.  It  is 
probable  that  such  funds  as  are  available  are  not  always  used  wisely. 
*  ♦  *.  The  administration  of  some  Insurance  Committees  and  of 
some  Public  Health  Authorities  in  this  matter  is  far  less  efficient  than 
that  of  others,  and  the  fact  that  these  two  bodies^  have  dual  and  over- 
lapping powers  is  inconvenient  and  undesirable." 

Further  testimony  as  to  the  unsatisfactory  character  of  the  pro- 
vision for  tuberculosis  may  be  found  in  the  report  of  a  Committee 
(February,  1017)  appointed  by  the  Faculty  of  Insurance  to  consider 
the  National  Insurance  Act.  This  Committee  cordially  endorsed  the 
results  of  the  medical,  sickness,  and  maternity  benefit  but  reported  as 
to  the  sanatorium  benefit  that  the  Act  had  been  disappointing;  "that 
the  tuberculosis  scheme  cannot  be  regarded  as  a  success  and  that,  in  all 
probability  much  better  results  would  be  obtained  were  the  existing 
system  of  overlapping  control  brought  to  an  end  and  the  whole  re- 
sponsibility vested  in  one  public  health  authority." 

The  Administration  of  Maternity  Benefit. 

This  benefit  has  been  perhaps  the  most  popular  feature  of  the  In- 
surance Act  and  the  one  that  has  presented  the  fewest  problems  from 
the  administrative  standpoint.  The  Act  originally  provided  for  the 
payment  of  a  lump  sum  of  30^.  ($7.30)  in  case  of  the  confinement  of  the 
wife  of  an  insured  person  or  a  woman  who  was  herself  an  insured  person 
whether  she  was  married  or  not.  An  insured  woman  was  under  the 
original  Act  also  entitled  to  sickness  benefit  or  disablement  benefit  after 
her  confinement.  A  further  provision  of  the  Act  was  that  where  the 
husband  was  an  insured  person  and  the  maternity  benefit  was  payable 
in  respect  of  his  insurance,  the  maternity  benefit  was  "the  husband^s 
benefit."  The  Act  did  indeed  provide  for  the  punishment  of  the  husband 
if  he  failed  to  make  provision  for  his  wife's  care,  but  this  was  like  lock- 
ing the  stable  after  the  horse  had  been  stolen.  An  Amending  Act  in 
1913  made  the  maternity  benefit  in  every  case  the  "mother's  benefit" 
j)ayable  only  to  the  woman  herself  or  to  the  husband  on  her  order. 

The  provision  in  the  original  Act  giving  a  woman  who  was  herself 
an  insured  person  the  right  to  sickness  benefit  during' confinement  in 
addition  to  the  husband's  maternity  benefit  when  her  husband  was  also 
an  insured  person  did  not  work  very  smoothly.  In  the  actuarial  scheme 
of  the  Act,  an  incapacity  of  four  weeks  was  allowed  for,  which  with  the 
sick  benefit  for  women  of  7s.  M.  a  week  would  have  meant  a  payment 
of  30».  as  sick  benefit  in  addition  to  the  30s.  maternitv  benefit.  Many 
societies  followed  the  policy  of  giving  an  additional  30s.  as  a  lump  sum 
in  such  cases  irrespective  of  the  period  during  which  the  insured  woman 
was  mcapaciated  for  work  by  reason  of  her  confinement,  whereas  the 
Act  obviously  intended  this  special  form  of  sickness  benefit  for  insured 
married  women  to  be  subject  to  the  same  conditions  as  are  attached  to 
sickness  benefits  generally,  viz.,  a  weekly  sum  payable  only  so  long  as 
the  society  is  satisfied  that  the  woman  is  actually  incapable  of  work. 


621 

Since  the  policies  of  the  different  societies  varied  so  much  with 
regard  to  the  payment  of  the  additional  30s.,  the  Amending  Act  of  1913 
provided  in  place  of  sick  benefit  for  insured  married  women  an  additional 
maternity  benefit  of  305.  payable  without  any  proof  of  "incapacity  for 
work"  being  required.  On  this  basis  maternity  benefit  is  being  dis- 
tributed at  the  rate  of.  approximately  a  million  pounds  annually,  305. 
going  to  every  mother  who  has  an  insured  husband  and  6O5.  to  every 
mother  who  is  herself  an  insured  woman. 

Until  the  passage  of  the  Amending  Act  of  1918  maternity  benefit 
was  payable  after  an  insured  person  had  been  26  weeks  in  insurance  and 
had  paid  26  contributions  (in  the  case  of  voluntary  contributors  52 
weeks  and  52  contributions).  The  1918  amendments  made  maternity 
benefit  pay-able  only  after  a  period  of  42  weeks'  membership  and  42  con- 
tributions (uniform  for  compulsory  and  voluntary  insured  persons). 
The  extension  of  the  period  of  26  weeks  was  found  to  be  necessary  in 
order  to  prevent  "  ^constructive'  entrance  to  insurance  for  the  purpose 
of  drawing  maternity  benefit."  It  was  believed  that  the  addition  of 
16  weeks  and  16  contributions  would  be  "an  effective  deterrent  to  a 
growing  tendency  to  engage  in  work  for  a  few  days  in  order  to  secure 
maternity   benefit."'^^ 

The  maternity  benefit  has  been  regarded  with  almost  universal 
approval.  Criticisms  made  by  such  organizations  as  the  Women's  Co- 
operative Guild  and  the  Fabian  Society^^  cover  two  points. 

1.  That  the  scope  of  the  Act  is  not  wide  enough  and  that  there  are 
still  too  manv  uninsured  mothers. 

2.  That  maternity  benefit  does  not  insure  adequate  attendance  at 
child-birth,  with  adequate  provision  for  infant  care. 

The  proposal  has  therefore  been  made  both  by  Mr.  Sidney  Webb's 
Fabian  Committee  of  Inquiry  and  by  the  Women's  Cooperative  Guild 
that  the  care  of  both  pregnancy  and  maternity  should  be  taken  out  of 
the  insurance  scheme  altogether  and  given  to  the  local  public  health 
authorities  assisted  by  grants-in-aid  from  the  government.  The  strain 
on  the  funds  of  societies  which  have  women  members  would  be  re- 
moved by  this  change,  and  proper  care  would  be  given  to  every  mother 
and  child  regardless  of  whether  or  not  either  or  both  parents  happen  to 
be  insured  persons  in  good  standing.  This  would  practically  make 
maternity  and  infant  care  a  non-contributory  form  of  state  aid,  and  it 
is  probable  that  such  provision  will  be  made  under  the  proposed  Minis- 
try of  Health.  Attention  should,  however,  be  called  to  the  opposition 
of  the  British  Medical  Association  to  this  plan.  The  Association  is  not 
in  favor  of  withdrawing  any  benefits  from  the  Insurance  Act  and  sub- 
stituting a  system  of  universal  provision  under  whole  time  state  medical 
officials.^* 


"  See  comments  in  the  Supplement  to  the  British  Medical  Journal,  November 
17.  1917.  p.  708. 

"  See  The  New  Statesman  Special  Supplement  on  the  Working  of  the  Insurance 
Act,  March  14,   1914,  p.   24. 

"  See  extract  from  letter  by  Insurance  Acts  Committee  of  the  British  Medical 
Association  to  National  Health  Insurance  Joint  Committee.  British  Medical  Journal, 
Supplement,   1917,  p.  101. 


Whatever  changes  the  future  may  bring  as  to  the.  extension  of 
maternity  benefit,  such  assistance  as  the  Insurance  Act  now  provides 
has  been  greatly  appreciated  by  those  who  know  conditions  of  life  among 
working  women.  E.  g..  Miss  Margaret  Llewelyn  Davies,  of  the  Women's 
Cooperative  Guild,  wrote  recently: 

"The  Maternity  and  Pregnancy  Sickness  Benefits  of  the  Insurance 
Acts  are  important  steps  in  the  direction  of  the  mothers'  economic  in- 
dependence. With  the  advent  of  a  Ministr}^  of  Health,  in  connection 
with  which  we  hope  to  see  a  strong  Maternity  and  Infancy  Department, 
largely  staffed  by  women,  an  opportunity  arises  for  deciding  the  relation 
which  Public  Health  and  Insurance  should  have  in  provision  for 
maternity  *  *  *.  But  Maternity  Benefit  has  been  an  epoch-making 
reform,  not  only  because  it  is  the  recognition  by  the  State  of  the  claims  of 
motherhood,  but  because  it  has  been  made  the  mother's  own  property."^ -^ 

Conclusions. 

How  far  has  the  British  Health  Insurance  experiment  succeeded? 
Much  can  be  said  in  criticism  of  various  points  of  administration,  and 
attention  is  too  often  concentrated  on  these  controversial  points.  Mr. 
Sidney  Webb,  whose  criticisms  of  the  Act  have  been  perhaps  too  fre- 
quently quoted  in  this  country,  said  that  he  had  dealt  largely  with  what 
he  believed  to  be  the  defects  of  the  scheme  in  order  that  alterations  and 
amendments  might  be  brought  under  discussion.  He  was  emphatic, 
however,  as  to  the  value  of  the  Act  as  a  whole  and  said  in  the  opening 
paragraph  of  his  well-known  Fabian  report: 

"We  cannot  pretend  to  measure  the  advantage,  to  individuals  or  to 
the  community,  of  the  really  gigantic  provision  thus  made  for  the  periods 
of  incapacity — however  far  short  of  completeness  or  perfection  the  pro- 
vision may  be  deemed.  However  faulty  in  plan  we  may  consider  the 
scheme  to  be,  and  however  defective  in  operation,  the  allocation  of  so 
large  a  sum  as  twenty  millions  [pounds]  per  annum  must  necessarily 
relieve  a  vast  amount  of  personal  suffering  and  mitigate  the  dire  pov- 
erty of  innumerable  families  in  their  hour  of  need.  Moreover,  though 
it  is  as  yet  too  early  to  enable  any  statistical  evidence  to  be  obtained,  it 
is  scarcely  possible  to  doubt  that  the  results  in  connection  with  public 
healh  and  infant  mortality  must  be  advantageous." 

The  following  table  summarizes  the  expenditure  of  the  Approved 
Societies  on  Sickness,  Maternity,  and  Disablement  Benefits  in  the  United 
Kingdom  from  the  beginning  down  to  the  year  1917. 


Sickness 
benefit. 


Maternity 
benefit. 


Disablement 
benefit. 


1913 

1014 

1915 

1916 

Total 


Total. 


£ 

6,554,687 
7, 210, 472 
6,303,942 
5,792,731 


25,861,832 


£ 
1,265,556 
1,470,252 
1,318,898 
1,260,268 


192, 180 

841,649 

1,145,989 


£ 

7, 820, 243 
8,872,904 
8,464,489 

8,198,988 


5,314,974 


2,179,818 


33,356,624 


^^  Women  and  the  Labour  Party  (edited  by  Marion  PhiUips),  p.  32-33. 


623 

The  expenditure  on  Sicknes^^,  ^laternity,  and  Disablement  Benefits 
alone  during  tlie  first  four  years  in  which  the  Act  Avas  in  operation  reached 
a  total  of  more  than  thirty-three  million  pounds,  and  this  entire  sum 
represents  money  paid  directly  into  the  homes  of  the  workers  to  relieve 
and  prevent  the  destitution  that  would  otherwise  be  caused  by  illness. 
It  is  these  benefits  which  have  been  in  part  responsible  for  the  decline 
of  poor  relief  in  various  parts  of  England.  It  has  been  said  for  example 
of  the  Liverpool  dock-hands  that  "In  50  per  cent  of  the  cases  where 
sickness  benefit  has  been  granted^  the  home  would  have  been  broken  up, 
the  furniture  sold,  and  the  family  engulfed  by  the  workhouse  if  it  were 
not  for  the  sickness  benefit  granted  by  the  Act.  Generally  also,  it  is 
said  that  there  is  less  of  what  the  doctors  call  "walking  sickness''  since 
the  Insurance  Act  has  come  into  force,  and  the  man  who  should  really 
be  in  bed  instead  of  struggling  with  pain  and  weakness  at  his  daily 
task  is  able  to  give  the  doctor  a  fair  chance  of  making  a  good  job  of  his 
case." 

The  Act  has  been  severely  criticized  by  Dr.  Brend  in  his  book  on 
Ilealth  and  the  State  on  the  ground  that  it  is  a  public  health  measure, 
that  its  main  object  was  to  improve  the  health  of  the  working  part  of 
the  community,  and  that  it  must  be  judged  solely  by  its  effect  on  public 
health. 

Aside  from  the  fact  that  it  is  much  too  soon  to  measure  the  effect 
of  the  Act  on  public  health,  these  criticisms  ignore  the  purpose  of  the 
Act  in  preventing  destitution.  The  National  Health  Insurance  Act  is 
a  public  health  measure  obviously,  but  it  is  also,  and  perhaps  primarily, 
an  Act  to  prevent  destitution  and  pauperism.  Mr.  Lloyd  George,  in 
introducing  the  bill,  said  that  it  was  a  direct  consequence  of  the  Old 
Age  Pensions  Act,  which  had  revealed  a  mass  of  poverty  "too  proud  to 
wear  the  badge  of  pauperism."  As  the  Old  Age  Pension  Act  had  been 
a  bill  to  prevent  pauperism  among  the  aged,  so  the  National  Health  In- 
surance Act  was  designed  to  prevent  the  pauperism  of  the  sick  and  to 
remove  the  workingman  and  his  family  from  the  poor  law  during 
periods  of  illness. 

Dr.  Brend  concludes  his  chapter  on  Health  Insurance  by  saying 
that  "in  taking  a  broad  view  the  advantages  of  the  Act  must  not  be 
minimized.  .  The  weekly  payments  of  sickness  benefit  have  undoubtedly 
lielped  many  poor  people  through  a  period  of  distress.  Maternity  bene- 
fit has  been  a  substantial  benefit  to  mothers  and  disablement  benefit  has 
constituted  a  small  pension  for  incapacitated  persons." 

Xevertheless  these  benefits  are  held  to  be  negligible  by  Dr.  Brend 
because  he  believes  that  the  effect  of  the  Act  on  the  public  health  during 
the  few  years  in  which  it  has  been  in  operation  "has  probably  been 
almost  nil/'  The  medical  service  is  said  to  be  no  better  than  "that 
which  .preceded  it,  "and  the  fact  that  this  service  is  available  now  to 
several  million  people  who  had  not  enjoyed  the  advantage  of  Friendly 
Society  Medical  Service  in  the  past  is  considered  of  no  importance. 
The  medical  service  under  the  panel  system  has  its  defects,  and  some  of 
them  have  been  referred  to  in  this  report ;  but  the  Health  Commissioners 
in  their  Second  x\nnual  Report  stated  the  case  very  fairly  as  to  medical 
benefit  with  all  its  drawbacks,  when  they  said : 


624 

"At  the  lowest  estimate  of  the  position,  an  enormous  number  of  men 
and  women  are  now  receiving  treatment  for  their  ailments  who  pre- 
viously were  accustomed  to  go  without;  while  on  the  other  hand,  in- 
sured persons  have  been  enjoying  at  the  hands  of  the  more  conscientious 
and  competent  doctors,  a  service  of  the  standard  of  that  accorded  to  re- 
munerative patients  of  the  well-to-do  classes." 

Further,  the  social  value  of  the  Act  should  not  be  overlooked.     On 
this  point  we  can  do  no  better  than  quote  Miss  Mary  Macarthur,  presi- 
dent of  the  largest  of  the  women's  trade  unions,  who  said  in  an  official  . 
report : 

"There  can  be  no  two  opinions  as  to  the  great  social  value  of  the 
Act,  in  revealing  the  conditions  of  the  mass  of  working  women,  and  the 
effect  which  their  low  wages  have  upon  their  health — questions  which 
up  to  now  have  been  almost  totally  neglected.  As  has  been  shown,  even 
doctors  in  poor  practices  have  been  amazed  at  the  amount  of  unexpected 
and  unrelieved  suffering  that  has  been  brought  to  light.  The  Act  has 
shown  the  country  what  poverty  means.  It  has  shown  that  people  who 
are  underfed,  badly  housed,  and  overworked  are  seldom  in  a  state  of 
physical  efficiency;  and  has  expressed  in  terms  of  pounds,  shillings  and 
pence  the  truth,  that  where  an  industry  pays  starvation  wages,  it  does, 
in  literal  sober  fact,  levy  a  tax  upon  a  community''  (Cd.  7687,  p.  86). 

In  conclusion,  emphasis  must  again  be  laid  upon  the  fact  that  the 
Health  Insurance  Act  in  Great  Britain  had  been  in  operation  only  two 
years,  and  that  the  most  important  benefits  had  been  administered  for 
only  a  year  and  a  half,  when  the  war  broke  out.  Inevitably  there  were 
many  inperfections  to  remedy  and  before  the  necessary  changes  could 
be  made,  the  great  war  began  to  absorb  the  resources,  the  time,  and  the 
thought  that  might  otherwise  have  gone  into  the  business  of  perfecting 
the  schemes  of  social  reform  that  had  been  launched  by  Mr.  Asquith's 
government. 

The  effect  of  the  war  in  retarding  the  development  of  the  Health 
Insurance  Organization  has  already  been  referred  to.  In  the  budget 
of  1914,  the  supplementary  estimate  contained  the  following  proposed 
Health  Insurance  Grants  from  the  National  Exchequer: 

AU  S^^P^^   Benefit    (Women)    (Grant  in  Aid) £500,000 

CII)   Medical   Referee   Consultants,    etc ^0  000 

(III)   Supplementary   Medical    Service roonn 

^}YA   Nursing  Grants   (Grant  In  Aid) 100  000 

(V)   Sanatorium   Benefit   (Grant  in  Aid) '..'.'.'.'.'.'.'.'.'.'.['.'.['.'.'.'.'.]'.  lOo'oOO 

Owing  to  the  outbreak  of  the  war  it  was  considered  inexpedient  to 
proceed  with  any  of  these  new  proposals.  It  soon  became  apparent  that 
all  the  work  of  the  depleted  staffs  of  the  National  Health  Insurance 
Commission  as  well  as  the  work  of  the  seriously  depleted  staffs  of  the 
local  Insurance  Committees  and  Approved  Societies  would  have  to  be 
dovoto^d  entirely  to  the  continuance  of  routine  work  under  the  Act.  On 
the  whole  It  IS  clear  that  the  war  has  had  a  definite  effect  in  retarding 

!l  nn^r^^"  .  ^^^  t  ^^T"""'"'  ^^^  '^  ''  ^^b'  fair  that  due  allowance 
should  be  made  for  the  setbacks  caused  by  the  war  in  assessing  the  re- 
sults of  this  great  British  experiment. 


625 


SPECIAL  REPORT  XVI.     THE  HEALTH  INSURANCE  MOVE- 

MENT  IN  THE  UNITED  STATES. 

(By  John  R.  Commons  and  A.  J.  AUmeyer.) 


[Note  by  the  Secretary. — Feeling  the  need  for  it  the  Commission  employed 
Professor  John  R.  Commons  to  prepare  a  brief  history  of  the  health  insurance 
movement  in  the  United  States.  He  was  selected  because  he  is  without  question 
the  leading  authority  in  this  country  in  the  field  of  labor  legislation  and  adminis- 
tration. Professor  Commons  is  Professor  of  Political  Economy  in  the  University  of 
Wisconsin,  a  former  president  of  the  American  Economic  Association,  and  a  member 
of  the  first  Industrial  Commission  of  Wisconsin.  He  has  been  assisted  by  Mr, 
Altmeyer,  an  Associate  in  the  University  of  Wisconsin,  in  gathering  the  data  pre- 
sented in  the  report  which  follows.] 

The  term  "social  insurance"  in  its  widest  sense  includes  all  insur- 
ance, since  insurance  is  but  the  social  distribution  of  individual  loss. 
But  the  term  as  here  used  applies  to  those  forms  of  insurance,  made 
more  or  less  universal  by  governmental  compulsion  or  subsidy  which  pro- 
tect the  wage-earning  class  against  personal  hazards.  Social  Insurance 
is  universal  compulsory  insurance  of  workers'  welfare.  In  Germany, 
the  term  first  used  was  Arbeiterversicherung  rather  than  Soziale  Ver- 
sicherung.  In  this  country  the  first  men  to  write  comprehensive 
treatises  on  the  subject  used  the  term  workingmen's  insurance. 

Social  insurance  at  present  covers  unemployment,  accident,  sickness, 
invalidity,  old  age  and  death^  or  rather  survivors'  insurance.  These 
different  forms  shade  one  into  another  somewhat.  Old  age  may  be  con- 
sidered a  form  of  invalidity  and,  in  fact,  is  included  in  Germany  with 
invalidity.  Invalidity  may  be  considered  extended  sickness  and,  accord- 
ingly, in  England,  is  included  with  sickness. 

Early  WHtings  on  Social  Insurance  in  the  United  States. 

The  first  ^mter  in  this  country  who  made  a  comprehensive  study 
of  social  insurance  was  John  Graham  Brooks.  His  book  was  published 
in  1893  as  the  Fourth  Special  Report  of  the  Commissioner  of  Labor.^ 
It  was  the  result  of  three  years'^  study  of  social  insurance  in  Germany, 
made  at  the  request  of  Carroll  D.  Wright,  then  Commissioner  of  Labor. 
Dr.  Brooks  was  very  favorably  impressed  with  the  working  of  the 
German  system.     Hi?  conclusions  were: 

"The  three  branches  of  the  German  nationl  workmen's  insurance — 
the  sickness,  accident,  invalidity  and  old  age  insurance — supplement- 
ing each  other  mutually,  from  a  complete  organization  and  have  resulted 
in  the  formation  of  a  new  workingmen's  code,  which  in  the  inevitable 
fluctuations  of  'modern  industrial  life,  will  afford  to  all  those  in  need 
of  assistance  a  welcome  aid,  and  in  its  further  development  cannot  fail 

iJohn  Graham  Brooks,  Fourth  Special  Report  of  the  Commissioner  of  Labor, 
"Compulsory  Insurance  in  Germany,"  Washington,   1893. 

—40  H   I 


620 

to  exercise  a  great  and  salutary  influence  in  the  economical  and  social 
conditions  of  the  working  people;  indeed,  on  the  whole  nation." 

The  report  by  Brooks  does  not  seem  to  have  aroused  much  interest. 
The  next  book  on  the  subject  was  that  of  Dr.  W.  F.  Willoughby,  published 
in  1898.2  rjij^-g  ^Qj.j,  covered  the  entire  social  insurance  movement  in 
Europe.  The  author  did  not  unqualifiedly  recommend  the  adoption  of 
the  entire  program  of  social  insurance  for  this  countr\-.  He  states,  "As 
regards  insurance  against  sickness,  nothing  short  of  absolute  necessity 
would  seem  to  warrant  the  intervention  of  the  state.  The  arguments  in 
favor  of  compulsion  are  much  stronger  in  the  case  of  insurance  against 
accidents."* 

Accident  Compensation. 

The  first  form  of  social  insurance  to  come  into  prominence  in  this 
country  wag  accident  compensation,  generally  termed  w^orkmen's  com- 
pensation. Willoughby  had  suggested  that  this  might  be  made  com- 
pulsory, but  Dr.  Adna  F.  Weber  of  the  New  York  Bureau  of  Labor  was 
the  first  to  present  a  detailed  study.  His  report  was  published  in  1899 
and  seems  to  have  been  the  first  contribution  that  definitely  separated 
out  workmen's  accident  compensation  from  other  forms  of  social  insur- 
ance."*  Prior  to  that  time  agitation  had  been  confined  entirely  to 
measures  designed  to  broaden  the  employer's  liability  laws.  As  Wil- 
loughly  remarked  in  1898,  "The  most  depressing  feature  of  the  situation 
lies  in  the  fact  that  the  very"  principles  involved  in  this  gradual  evolution 
from  the  limited  liability  of  employers  to  that  of  the  compulsory  in- 
demnification by  them  of  practically  all  injured  employees,  are  as  yet 
not  even  comprehended  in  the  United  States."^ 

It  was  not  yet  clearly  perceived  that  extension  of  the  law  of  negli- 
gence would  not  avail.  Xo  analysis  of  accident  statistics  had  been  made 
in  this  country  to  show  the  large  proportion  of  accidents  not  due  to  any 
one's  negligence,  either  that  of  the  employer,  the  employee,  or  a  fellow- 
servant.  Even  had  this  been  realized,  public  opinion  was  not  5^et  ready 
to  admit  tliat  industry,  as  represented  by  the  employer,  must  pay,  re- 
gardless of  negligence. 

In  1899  an  effort  was  made  in  N'ew  York  to  pass  a  bill  based  on 

tlie  principle  of  absolute  liability  and  compensation,  but  it  failed  on 

account  of  the  contemporaneous  demand  for  a  more  stringent  liabilitv 
law.*'  • 

It  is  significant  that  the  agitation  for  workmen's  compensation  in 
this  country  took  definite  shape  immediately  after  the  passage  of  the 
British  Workmen's  Compensation  Act  of  1897.  Undoubtedlv,  the  move- 
ment here  was  stimulated  by  the  passage  of  that  act  and"^  subsequent 
amiMidatory  acts,  including  the  Workmen's  Compensation  Act  of  1906. 
All  of  tlie  British  acts  provided  for  compensation  to  be  paid  largelv  with- 
out ro.irard  to  individual  responsibility. 

l^llr  f-  willoughby.  Workingmbn's  Insurance,  1898 
•  Ibid.,  p.   344,  .  ' 

pp.  55^7-1162''*'"''*  ^""""^  Report  of  Bureau  of  Labor  Statistics  of  New  York,  1899. 

ly^i-  ^-  WniouKhby,  Workingmeti's  Insurance,  1898,  p.  329. 
Charles  R.  Henderson,  Industrial  Insurance  in  the  United  States,  1909,  p.   144, 


627 

The  cnide,  inadequate  and  unworkable  law  of  Maryland  in  1902 
marks  the  beginning  of  workmen's  compensation  legislation  in  this 
country."^  The  Federal  Workmen's  Compensation  Act  of  1908  was  the 
first  workable  compensation  act,  inadequate  though  it  was.  In  1909 
the  states  began  to  appoint  special  legislative  commissions  to  study  the 
problem.  The  report  of  these  commissions,  together  with  the  report  of 
the  United  States  Bureau  of  Labor  in  1909,  furnished  an  abundance  of 
information.® 

In  1910  bath  Montana  and  N'ew  York  passed  acts  which  were  later 
declared  unconstitutional.  The  year  1911  marks  the  date  of  the  first 
permanent  state  laws.  In  this  year  the  following  ten  states  in  the  order 
named  passed  compensation  laws;  Washington,  Kansas,  Nevada,  New 
Jersey,  California,  New  Hamphire,  Wisconsin,  Illinois,  Ohio  and  Massa- 
chusetts. To-da}'  there  are  thirty-seven  states  and  three  territories  with 
such  laws.^ 

Dr.  Weber  in  1902^°  and  Professor  Seager  in  1910^^  both  ventured 
the  opinion  that  the  English  system  of  workmen's  compensation,  wherein 
the  employer  is  permitted  to  select  his  insurance  carrier,  rather  than  the 
German  system  of  compulsor}^  insurance  in  mutual  societies,  was  best 
suited  to  conditions  in  this  country.  Their  opinions  seem  to  have  gauged 
the  American  attitude  correctly,  since  in  thirty  of  the  states  the  employer 
is  given  an  option  as  to  the  method  of  insuring  his  risk^^  and  in  twenty- 
eight  states  self-insurance  is  permitted.^^ 

Occupational  Diseases. 

While  the  states  were  still  in  the  process  of  passing  compensation 
acts  covering  accidents,  agitation  was  begun  to  include  occupational  dis- 
eases. Possibly  the  fact  that  certain  occupational  diseases  were  covered 
in  the  British  Compensation  Act  of  1906  may  have  had  some  influence 
on  this  discussion.  In  1910,  Dr.  John  B.  Andrews,  Secretary  of  the 
American  Association  for  Labor  Legislation,  said:  "No  intelligent  per- 
son can  go  far  in  the  study  of  compensation  for  industrial  accidents 
without  realizing  that  a  logical  consideration  of  the  facts  must  lead  to 
compensation  for  industrial  diseases."^* 

The  logic  of  providing  compensation  for  occupational  diseases  is 
apparent  from  the  definition,  "Occupational  diseases  are  morbid  results 
of  occupational  activity  traceable  to  specific  causes  or  labor  conditions, 
and  followed  by  more  or  less  extended  incapacity  for  work."^^  The  great 
obstacle  to  legislation  along  this  line  is  the  difficulty  of  administration. 

In  some  states  the  word  "injury"  in  workmen's  compensation  acts 
has  been  construed  bv  the  commissions  and  courts  to  include  diseases. 
This  is  so  in  the  case  of  Massachusetts  and  the  Federal  Government.     In 


''U.  S.  Bureau  of  Laboi'  Statistics,  Bulletin  No.  240,  "Comparison  of  Work- 
men's Compensation  Laws  of  the  United  States,"  1918,  p.   10. 

*  Twenty-fourth  Annual  Report,  U.  S.  Comimssioner  of  Labor,   1909,  2  vol. 

»U.  S.  Bureau  of  Labor  Statistics,  Bullp:tin  No.  240,  1918,  p.  9. 

^"  Employer's  Liability  and  Accident  Insurance,  Political  Science  Quarterly ,  Vol. 
XVII,  1902,  p.  282. 

"Henry  R.  Seager,  Social  Insurance,  1910,  pp.  74-75. 

"U.  S.  Bureau  of  Labor  Statistics,  Bulletin  240,  1918,  p.   15. 

"Ibid.,  p.  40. 

"^^  Bulletin  on  Industrial  Diseases  and  Occupational  Staiidards,  May,   1910. 

^^  American  Labor  Legislation  Review,  Vol.  1,  No.  1,  January,  1911,  pp.  125-143, 
Memorial  on  Occupational  Diseases. 


628 

California  and  Hawaii  the  inclusion  of  occupational  diseases  has  been 
brought  about  by  statutory  enactments."  No  state  has  followed  the 
British  plan  of  providing  a  definite  schedule  of  compensatable  occu- 
pational diseases.  This  method  is  considered  by  the  Committee  on 
Occupational  Diseases  of  the  :N'ational  Conference  of  Commissions  on 
Uniform  State  Laws  as  "the  only  practicable  way  of  dealing  with  the 

matter."^^ 

The  British  Act  of  1906  covered  six  occupational  diseases,  which 
number  has  since  been  increased  to  twenty-eight.  Only  .the  most  appar- 
ent occupational  diseases  can  be  included  (such  as  anthrax,  lead  poison- 
ing, glass  blower's  cataract)  and  even  then  the  responsibility  is  often 
htSd  to  fix.  When  the  onset  of  the  disease  is  gradual,  as  in  the  case  of 
lead  poisoning,  it  is  hard  to  determine  which  employer  is  responsible,  if 
the  workman  has  been  employed  by  more  than  one. 

If  it  is  difficult  to  fix  the  responsibility  in  the  case  of  those  diseases 
to  which  the  public  at  large  is  not  subject,  it  is  practically  impossible 
to  do  so  in  the  case  of  "diseases  to  which  the  public  is  subject,  but  which" 
mav  be  caused  or  aggravated  or  accelerated  by  specific  conditions  of 
labor."" 

Undoubtedly,  workers  in  the  so-called  "dusty  trades"  have  an  ex- 
cessively high  death  rate  from  tuberculosis,  but  it  is  impossible  to 
establish  the  causal  connection  in  individual  cases.  It  is  also  true  that 
monotony  of  work,  speeding-up,  a  long  work  day,  and  inadequate  wages 
undermine  one's  health  and  resisting  power,  but  these  facts  could  hardly 
be  made  the  basis  for  legal  action. 

A  way  out  of  the  difficulty,  which  has  been  proposed,  is  to  make 
industry  responsible  for  all  occupational  diseases,  the  causes  of  which 
can  be  definitely  allocated,  and  to  provide  compulsory  contributory  health 
insurance  for  all  employees.  Health  insurance  would  then  take  care  of 
occupational   diseases  not  compensated. 

Advocates  of  compulsory  health  insurance  point  out  that  in  the  two 
states  where  occupational  diseases  are  covered  by  the  workmen's  com- 
pensation law,  the  number  of  cases  for  which  compensation  is  allowed 
is  negligible.^® 

While  compulsory  health  insurance  may  be  regarded  as  a  logical 
development  of  accident  compensation,  it  is  more  than  an  extension. 
Underlying  both  accident  compensation  and  compulsory  health  insurance 
is  the  theory  of  social  solidarity.  In  accident  compensation  the  purpose 
was  to  make  industry  bear  the  cost  of  the  damage  and  destruction  of  the 

««•  ®'  ^"reau  of  Labor.  Bulletin  240,  1918.  p.  45. 

"  Proceedings  of  the  Twenty-seventh  Annual  Meeting  of  the  National  Conference 
of  Commissloner.«j  on  Uniform  State  Laws. 

"  See  classification  of  the  Committee  on  Occupational  Diseases,  whose  report 
na.«>i  been  referred  to  above. 

T  ^  "^.^'i  A^'^'^P'^'i"  Massachusetts,  of  135,257  personal  injuries  reported  to  the 
Indv  -  Accident  Board  in  the  year  1915-16,  onlv  2029,  or  1.5  per  cent,  were  cases 
or  '  tlonal  di.sease.      (Annual  Report  of  the  Massachusetts  Industrial  Accident 

Board,  July  1.  1915  to  Juno  30.  1916,  p.  70)  In  California,  in  1915,  67,538  injuries 
were  reported  to  the  Industrial  Accident  Commission,  but  from  the  time  the  law 
requiring'  the  reporting  of  occupational  diseases  went  into  effect,  August  8,  1915, 
K^'iVo»-A'  ^^^®'  °^^Y.  *^\  ^'seases  were  reported.  It  was  thought  that  these  might 
««««  h^^*l.^®  ^*^«"P*^V**"i^^  diseases,  although  at  the  time  of  the  report  the  Commis- 
si J^c^?  not  definitely  decided.  (Report  of  the  Industrial  Accident  Commission  of 
the  State  of  California  from  July  1,  1915,  to  June  30,  1916,  pp.  42  and  43.) 


629 

human  factor  as  it  already  did  for  machinery.     Sickness,  however,  may 
exist  entirely  apart  from  industry 

The  American  Association  for  Labor  Legislation. 

It  is  interesting  to  observe  that  agitation  for  health  insurance  began 
in  this  country  in  1912,  soon  after  the  passage  of  the  British  National 
Insurance  Act  of  1911,  just  as  agitation  for  accident  compensation  began 
soon  after  the  passage  of  the  British  Workmen's  Compensation  Act  of 
1897. 

The  first  attempt  to  formulate  a  plan  of  compulsory  health  insur- 
ance adaptable  to  conditions  in  the  United  States  was  that  of  the 
American.  Association  for  Labor  Legislation  m  1912.  This  association 
is  a  branch  of  the  International  Association  for  Labor  Legislation, 
whose  headquarters  are  at  Basle,  Switzerland.  The  International  Asso- 
ciation, which  is  a  federation  of  associations  in  fifteen  different  countries, 
was  founded  at  Paris  in  1900,  to  promote  progressive  industrial  legis- 
lation in  all  nations  and  an  international  knowledge  of  labor  laws.  Prior 
to  the  world  w^ar  the  International  Association  received  subventions  from 
twenty-two  national  governments,  including  a  contribution  on  account 
of  services  from  the  United  States  Department  of  Labor.  Its  publi- 
cations are  issued  in  the  three  languages,  English,  French  and  German. 

The  American  Association  was  founded  in  1906  and  affiliated  with 
the  International  Association.  Its  objects  were  to  sen^e  as  a  branch 
of  the  latter,  to  promote  uniformity  in  labor  legislation  among  the 
several  states,  and  to  encourage  the  study  of  labor  legislation.^*^  Health 
insurance  is  but  one  of  the  several  activities  of  this  association,  other 
activities  being  legislation  for  protection  against  accidents  and  disease, 
the  taxation  of  poisonous  phosphorus  matches  out  of  existence,  the  pro- 
motion of  the  Federal  Compensation  Law,  as  well  as  workman^s  com- 
pensation laws  in  various  states,  accident  reporting  and  legislation  to 
secure  better  administration  of  labor  laws. 

In  December  1912,  the  Association  created  its  first  national  com- 
mittee on  social  insurance,  which  organized  the  First  National  Con- 
ference on  Social  Insurance,  held  in  Chicago  in  June  1913.  After 
extensive  investigation  and  a  number  of  meetings^  the  Social  Insurance 
Committee  in  the  summer  of  1914  issued  a  tentative  statement  of  the 
essential  lines  it  would  follow  in  the  drafting  of  a  sickness  insurance  bill. 

Finally,  in  November  1915,  with  the  cooperation  of  a  committee 
of  the  American  Medical  Association,  the  first  tentative  draft  of  an  act 
for  health  insurance  was  published.  A  few  months  later  the  measure 
was  introduced  in  the  legislatures  of  New  York,  Massachusetts  and  New 

*<*The  President  of  the  American  Association  for  1918  is  Samuel  McCune  Lind- 
say. The  Secretary  is  John  B.  Andrews  of  New  York.  The  Executive  Committee, 
which  is  representative  of  its  membership  composed  of  labor  leaders,  employers  and 
scientific  men,  consists  of :  T.  L.  Chadbourne,  Jr.,  lawyer.  New  York  City ;  Henry 
W.  Farnam  and  Irving  Fisher  of  Yale  University  ;  Edmund  N.  Huyck,  manufacturer, 
Albany,  New  York ;  V.  Everit  Macy,  capitalist,  New  York  City ;  Royal  Meeker, 
Chief  of  the  United  States  Bureau  of  Labor  Statistics,  Washington  ;  John  Mitchell, 
former  president  of  the  United  Mine  Workers  of  America,  Mount  Vernon,  New 
York ;  Margaret  Dreier  Robins,  president  of  the  National  Women's  Trade  Union 
League  of  America,  Chicago;  John  A.  Voll,  president  of  the  Glass  Bottle  Blowers' 
Association  of  the  United  States  and  Canada,  Philadelphia. 


630 

Jersey.-^     This  bill  has  come  to  be  known  as  the  "Standard_Bill"  and 
will  be  discussed  later." 

Jnvestigaiing  Commissions. 

While  in  1915  there  were  three  legislatures  in  which  the  standard 
bill  was  introduced,  there  were,  in  1917,  twelve  state  legislatures  that 
considered  health  insurance  bills.  Altogether,  the  legislatures  of  eight 
states  have  appointed  commissions  which  have  investigated  the  subject. 
The  first  commission  to  report  was  that  of  California.,  appointed  in  May 
1915.  While  it  was  authorized  to  make  a  study  of  social  insurance,  it 
concentrated  on  health  insurance.  _The  Commission,  in  its  report  to  the 
legislature  January  1917,  was  unanimous  in  favoring  compulsory  health 

insurance. 

The  second  commission  to  report  was  that  of  Massachusetts,  created 
in  1916.  This  commission  investigated  sickness,  unemployment,  old 
age  and  hours  of  labor.  Its  report,  submitted  in  February,  1917, 
endorsed  the  principle  of  health  insurance  unanimously.  Five  of  the 
members  favored  the  immediate  adoption  of  compulsory  health  insur- 
ance of  the  type  usually  proposed.  Two  felt  that  there  should  be  more 
investigation,  while  two  more  felt  that  if  a  compulsory  system  were 
adopted,  the  employee  should  not  be  required  to  contribute. 

New  Jersey  had  appointed  a  Commission  in  1911  to  invesigate 
old  age  insurance.  This  Commission  submitted  a  report  in  November 
1917,  stating  its  belief  that  "health  protection  should  precede  any  pro- 
vision for  old  age.-^  It,  therefore,  recommended  the  adoption  of  a 
health  insurance  measure,  presumably  compulsory.  The  Commission 
felt  that  the  need  for  such  a  measure  was  especially  great  at  that  time, 
because  of  the  war  situation. 

Meanwhile,  Massachusetts  had  created  another  Commission  to 
concentrate,  this  time,  on  health  insurance.  This  second  Commission 
reported  January  15,  1918.  Nine  members  voted  against  compulsory 
health  insurance  and  two  voted  in  favor  of  compulsory  health  insur- 
ance with  no  contributions  from  the  employee.  From  a  perusal  of  the 
report  it  would  seem  that  the  Commission  was  concerned  particularly 
with  the  problem  of  ascertaining  the  attitude  of  different  interests.  The 
report  states  that  "an  analysis  of  the  evidence  reveals  no  growing  demand 
in  the  Commonwealth  for  compulsory  contributory  health  legislation." 

At  present,  January,  1919,  there  are  six  Commissions  still  at  work 
-which  will  report  at  the  next  meeting  of  the  legislatures.  They  are: 
California  (reappointed),  Connecticut,  Illinois,  Ohio,  Pennsylvania,  and 
Wisconsin.     The  house  committee  authorized  in  New  Hampshire  has 

"John  B.  Andrews:  Address  before  Twelfth  Annual  Meeting  of  the  National 
Association  for  the  Study  of  the  Prevention  of  Tuberculosis,  Mav,  1916, 

» The  members  of  the  Committee  on  Social  Insurance  that  drafted  this  bill 
were :  Miles  M.  Dawson.  Consulting  Actuary ;  Edward  T.  Devine  Director  New 
York  School  of  Philanthropy;  Carroll  W.  Doten,  Secretary  of  the  American  Statis- 
tical Association  ;  S.  S.  Goldwater,  formerly  Commissioner,  Department  of  Health, 
City  of  New  York ;  Henry  J.  Harris,  Chief,  Division  of-  Documents,  Library  of 
Congress;  Alexander  Lambert,  Chairman  of  Social  Insurance  Committee,  American 
Medical  Association;  I.  M  Rubinow.  Actuary  and  Statistician;  Henry  R.  Seager. 
Professor  of  Economics,  Columbia  University;  Lillian  D.  Wald,  Head  Resident, 
Henry  Street  Settlement :  John  B.  Andrews.  Secretary,  American  Association  for 
Labor  Legislation. 

"Report  on  Health  Insurance  by  the  New  Jersey  Commission,  1917,  p.  4. 


031 

not*  been  appointed.  These  C^ommissions  have  held  two  national  con- 
ferences, one  in  December  1917  at  Philadelphia  and  one  in  May, 
1918,  at  Cleveland,  to  discuss  problems  and  methods.^* 

It  would  seem  that  we  have  reached  the  same  stage  in  health,  in- 
surance legislation  as  was  reached  in  accident  compensation  legislation 
nine  years  ago ;  the  period  of  legislative  investigating  Commissions.  As 
yet  no  bill  providing  for  compulsory  health  insurance  has  been  passed. 

Basis  of  Agitation  for  Compulsory  Health  Insurance. 

It  is  not  intended  here  to  discuss  the  merits  of  the  proposals  for 
compulsory  health  insurance,  but  in  order  that  the  attitude  of  the  differ- 
ent interests  may  be  proper h^  understood,  it  seems  advisable  to  state 
briefly  the  main  arguments  which  have  been  advanced  pro  and  con. 

Underlying  the  agitation  for  compulsory  health  insurance  is  the 
belief  that  there  exists  an  excessive  amount  of  sickness;  that  such  sick- 
ness is  one  of  the  principal  causes  of  poverty ;  and  that  existing  agencies 
are  inadequate  either  to  prevent  or  distribute  equitably  the  cost  of  such 
sickness. 

As  evidence  of  the  amount  of  sickness  or  disability  prevalent,  the 
Report  of  the  Provost  Marshal  General  on  the  First  Draft  under  the 
Selective  Service  Act  in  1917,  is  cited.  From  this  report,  (pp.  44,  45) 
it  is  estimated  that  about  35  per,cent  of  those  registered  were  rejected, 
as  physically  disqualiSed  for  service.  The  investigation  made  for  the 
Federal  Commission  on  Industrial  Eelations  by  Dr.  B.  S.  Warren  and 
Edgar  Sydenstricker,  regarding  industrial  conditions  and  the  public 
health,  led  to  the  conclusions  that,  among  the  thirty-odd  million  wage- 
earners  in  the  United  States,  there  is  an  average  of  nine  days  a  year 
lost  through  sickness,  a  total  wage  loss  of  $500,000,000,  and  a  medical 
cost  of  $180,000,000.25 

Responsibility  \''>v  -ickric—  i-  -vnerally  attributed  to  three  factors. 
The  industry  is  held  responsible  for  a  certain  portion,  as  indicated  by 
the  varying  rates  of  morbidity  and  mortality  for  different  occupations. 
The  health  hazard  of  some  occupations  (judging  from  the  rate  of  in- 
surance companies)    is  double  that  of  the  least  hazardous  occupation. 

The  community  is  held  responsible  for  the  portion  of  sickness  due 
to  conditions  under  its  control,  such  as  housing,  food,  water  supply, 
sewage  disposal,  and  the  community  enviornment  in  general.  Such 
diseases  as  typhoid,  scarlet  fever,  diptheria  and  other  epidemic  diseases 
are  clearly  susceptible  to  community  control. 

But  it  is  impossible  to  go  into  a  man's  house  and  force  him  to 
observe  the  rules  of  personal  h3'giene,  so  that  the  individual  is  responsi- 
ble for  that  portion  of  sickness  due  to  failure  to  observe  the  rules  of 
right  living.  Because  of  the  joint  responsibility  of  these  three  factors, 
all  three  are  assessed,  in  most  of  the  schemes  proposed,  a  portion  of  the 
cost  of  compulsory  health  insurance. 

The  partnership  of  disease  and  poverty  is  considered  by  the  ad- 
vocates of  compulsory  insurance  as  a  matter  of  common  observation  and 

2*  Reports  of  these  conferences  are  contained  in  Vol.  VIII,   1918,  Nos.   1  and  2 
of  the  A^nerican  Labor  Legislation  Review. 

^  Final  report  of  the  Commission  on  Industrial  Relations,   1915,  p.  202. 


N 


632 

the  studies  of  infant  mortality  made  by  the  Children's  Bureau  are  pointed 
to  as  showing  that  the  rate  of  infant  mortality  varies  inversely  with 
the  family  income.  Likewise  it  is  argued  that  the  extra  expense  and  the 
loss  of  wages  caused  by  sickness  often  wipe  out  any  surplus  in  the  family 
budget  and  force  the  afflicted  family  on  charity.  Devine  states  that 
of  the  destitute  families  coming  under  the  care  of  the  Charity  Organi- 
zation Society  in  New  York  City,  three  fourths  were  found  to  be  desti- 
tute wholly  or  partly  on  account  of  sickness.^^ 

It  is  asserted  that  those  who  are  sick,  being  unable  to  afford  it,  do 
not  receive  adequate  medical  attention.  The  Health  Survey  made  by 
the  City  Club  of  Milwakee  states  that  40,000  persons  were  sick  at  the 
time  of  the  survey.  Of  these,  25,700  or  64.7  per  cent  would  have  been 
entitled  to  medical  care  under  a  compulsory  health  insurance  bill  such 
as  the  one  introduced  in  New  York  and  Massachusetts.  Of  those  who 
would  have  been  entitled  to  medical  aid,  only  11,000  were  under  a 
doctor's  care.  On  the  other  hand,  the  sickness  surveys  of  the  Metro- 
politan Life  Insurance  Company  do  not  show  a  large  percentage  of  those 
sick  without  medical  care.  Their  percentage  of  cases  of  sickness  with- 
out medical  attendance  range  from  24.2  per  cent  in  Pittsburgh  to  39 
per  cent  in  Rochester,  N.  Y.^^ 

It  is  contended  by  many  who  favor  compulsory  health  insurance 
that  contributions  by  the  three  factors  responsible  will  distribute  the 
burden  equitably.  It  is  claimed  that  the  one  who  is  sick  will  then  be 
assured  adequate  medical  attention  and  the  family's  income  will  not 
entirely  cease,  by  reason  of  cash  benefits  to  be  provided. 

Advocates  of  compulsory  health  insurance  believe  that  existing 
voluntary  insurance  carriers  cannot  take  care  of  the  problem,  because 
not  enough  people  are  insured  and  those  who  are  insured  as  a  rule  carry 
only  enough  insurance  to  provide  funeral  expenses.  Studies  made  of 
family  budgets  show  that  a  majority  of  families  carry  insurrance  of 
some  sort.  Chapin  found,  however,  that  the  insurance  was  "not  a  pro- 
vision for  a  rainy  day,  but  a  provision  for  meeting  a  single  contingent 
expense;  viz.  the  cost  of  burying  the  dead."^^  Mrs.  More  found  that 
"the  insurance  invariably  goes  to  meet  the  expenses  of  the  funeral  or  of 
the  last  illness."^^ 

It  is  also  contended  that  the  cost  of  voluntarv  insurance  is  excessive, 
especially  in  the  case  of  industrial  insurance.  The  assertion  is  made 
regarding  industrial  accident  and  health  insurance  that  only  about  one- 
third^°  or  two-fifths  of  the  premiums  are  returned  in  the  form  of  bene- 
fits to  the  insured.  The  excessive  cost  is  considered  inevitable  because  of 
the  necessity  of  loading  premiums  to  cover  the  necessary  expense  of  secur- 
ing and  conducting  the  business.  With  wholesale  compulsory  health  in- 
surance, it  is  believed  that  competitive  and  retail  costs  will  be  eliminated. 

"E.  T.  Devine,  Misery  and  Its  Causes,  1910,  p.  54. 

"See  pamphlets  issued  by  Metropolitan  Insurance  Company,  covering  sickness 
surveys  of  I^'ttsburgh.  Penn. ;  Principal  cities  in  Pennsylvania  and  West  Virginia ; 
Chelsea  Neighborhood,  N.  Y.  City :  and  Kansas  City,  Mo. ;  also  reprints  published 
by  the  U.  S.  Public  Health  Service  of  sickness  surveys  of  North  Carolina  and 
Rochester.  N.  Y.,  made  by  officers  of  the  same  company. 

"R  C.  Chnpln.  The  Standard  of  Living  in  New  York  City,  1909,  p.  192. 

••I.oulse  B.  More.  Wagc-carncrs'  Budgets,  1907,  p    43 

•"I.  M.  Rublnow,  Social  Insurance,  1913,  p.  296 


633 

Another  advantage  claimed  for  compulsory  health  insurance  is  that 
it  will  have  a  preventive  effect.  It  is  stated  that,  just  as  the  number 
of  accidents  was  reduced  when  workmen's  compensation  laws  went  into 
effect,  so  will  the  amount  of  sickness  be  reduced  when  the  employer  and 
employee  see  that  it  pays  to  take  precautions  against  sickness. 

XJie  co,si_QJLhealth  insurance  is  generally  estimated  as  a  percentage 
jd  the  pa3Toll.  The  estimate  usually  given  is  4  per  cent.  This  cost 
varies  directly  with  the  benefits  provided.  Advocates  of  compulsory 
health  insurance  point  out,  however,  that  the  costs  are  only  made  visible 
and  distributed  equitably.  They  contend  that  a  rational  method  of 
carrier  does  not  increase  the  cost,  but  may  lighten  it,  as  has  been  the  case 
with  workmen's  compensation.  Doctors  have  been  paying  in  the  form 
of  charity  work;  emploj^ers  because  of  decreased  output,  due  to  worry 
and  neglected  cases  of  sickness  among  the  employees ;  employees  through 
reduced  earning  power ;  and  the  whole  community  through  contributions 
to  charity  and  in  increased  amount  of  sickness. 

Arguments  Agcdnst  Compulsory  Health  Insurance. 

The  opponents  of  health  insurance  assert  that  the  mortality  and 
morbidity  experience  of  this  country  is  more  favorable  than  that  of 
Germany,  the  first  country  to  adopt  compulsory  health  insurance. 
"Thus,  for  Boston,  Mass.,  the  average  sickness  loss  for  males  is  only 
6.3  days  per  annum,  and  for  Rochester,  N.  Y.  the  loss  is  7.0  days, 
against  more  than  9.2  days  for  Germany  and  9.5  for  Austria."^^  It  is 
also  claimed  that  the  mortality  experience  among  the  industrial  popu- 
lation is  as  favorable  as  that  of  the  population  at  large.^^ 

The  increase  in  the  amount  of  savings  banks'  deposits  is  ojffered 
as  proof  that  wage-earners'  budgets  are  sufficient  to  provide  for  proper 
care  and  needs  of  dependents. 

Existing  insurance  agencies  are  considered  adequate  and  more  effi- 
cient than  a  state  owned  or  controlled  system.  These  voluntary  agencies 
are  believed  to  encourage  thrift  and  foster  independence.  It  is  also 
contended  that  prevention  is  not  the  function  of  insurance.  Therefore, 
it  is  urged  that  public  health  administration  and  preventive  medicine 
be  developed  instead. 

As  positive  objections  to  compulsory  health  insurance  it  is  claimed 
that  such  a  system  is  not  in  accord  with  our  theory  of  government ;  that 
it  is  Prussianistic,  Socialistic  or  paternalistic  in  its  nature;  that  it 
restricts  personal  liberty.  It  is  also  alleged  that  the  moral  effect  on  the 
workman  will  be  bad  and  that  it  will  lead  to  malingering.  Finally  it  is 
urged  that  the  status  of  the  medical  profession  will  be  lowered,  because 
of  overwork,  burdensome  details,  suppression  of  initiative  on  the  part  of 
physicians,  and  insufficient  remuneration. 

The  following  specific  counter-suggestions  have  been  made: 

1.  Development  of  state  medical  care  to  provide  care  for  all. 

2.  Development  of  public  health  agencies. 

3.  Education  in  personal  and  public  hygiene. 

»*  Frederick  L.  Hoffman,  Facts  and  Fallacies  of  Compulsory  Health  Insurance, 
Prudential  Press,   1917,  p.  89. 

32  Magnus  W.  Alexander,  "Some  Vital  Facts  and  Considerations  in  Respect  to 
Compulsory  Health  Insurance,"  Bulletin,  March,  1917,  p.  7. 


634 

4.  Development  of  institutional  and  group  facilities  for  the  treat- 
ment of  disease:  hospitals,  dispensaries,  diagnostic  stations. 

5.  Compensation  for  occupational  diseases. 

6.  Development  of  voluntary  insurance  carriers. 

7.  Development  of  institutions  to  encourage  thrift. 

8.  Shorter  hours,  better  pay  and  better  conditions  for  labor. 

The  Standa/rd  Bill. 

The  Standard  Bill  of  the  American  Association  for  Labor  Legis- 
lation, as  published  June  1916,  covers  all  manual  employees  and  all 
other  employees  receiving  less  than  $1,200  per  annum.  Home-workers 
and  casual  workers  may  be  included  by  administrative  order.  It  pro- 
vides benefits  for  all  sickness,  accidents,  and  death  not  covered  by  work- 
men's compensation. 

The  cash  benefits  are  &&%  per  cent  of  the  wages  for  a  period  not 
to  exceed  2&  weeks  in  any  consecutive  twelve  months.  The  medical 
benefits  consist  of  medical,  surgical  and  nursing  assistance  and  treat- 
ment; medicines  and  therapeutic  appliances  costing  not  more  than  $50 
in  any  one  year;  hospital  care;  medical  and  surgical  treatment  and 
medicines  to  dependents. 

Maternity  benefits  are  provided  for  insured  women  and  the  wives  of 
insured  men,  consisting  of  cash  and  medical  benefits  to  the  former  and 
medical  benefits  to  the  latter. 

If  the  hospital  care  is  given  the  insured,  the  cash  benefits  are  re- 
duced to  one-third  of  the  wages.     Funeral  benefits  up  to  $50  are  allowed. 

Employers  are  obliged  to  contribute  2/5,  employees  2/5  and  the 
state  1/5  of  the  expenses.  If  the  earnings  of  the  insured  are  less  than 
$9  a  week,  his  contribution  is  reduced.  Employees  earning  less  than  $5 
a  week  contribute  nothing.  In  such  cases  the  employer  makes  up  the 
difference. 

'  The  bill  provides  for  the  organization  of  local  funds.  In  cities 
where  there  is  a  large  enough  number  of  employees  in  a  trade,  trade 
funds  are  to  be  organized.  Each  of  these  funds  is  to  be  managed  by 
a  committee  composed  of  representatives  of  employers  and  employees. 
This  committee  in  turn  elects  a  representative  board  of  directors  to 
carry  out  its  policies. 

Xon-profit  making  insurance  carriers,  such  as  fraternals,  labor 
unions  and  establishment  funds  may  come  into  the  system  under  rather 
discouraging  conditions.  The  employer's  contribution  except  in  the 
case  of  establishment  funds  must  be  paid  into  a  state  guaranty  fund, 
instead  of  to  the  society.  If  the  operation  of  such  a  society  endangers 
the  existence  of  a  local  or  trade  fund,  it  may  be  compelled  to  discon- 
Tinup.     Commercial   insurance   companies   are   excluded   entirely. 

The  medical  service,  to  be  provided  may  be  along  either  of  the  fol- 
lowing lines: 

1.  A  panel  of  physicians  to  which  all  legally  qualified  physicians 
may  belong,  with  freedom  of  choice  of  physician  on  the  part  of  the 
insured.  The  number  of  persons  on  the  list  of  any  one  physician  may 
not  exceed  1,000.  ^  r  . 


635 

2.  Salaried  physicians  lu  the  emplo}'  of  the  carriers,  with  reasonable 
free  choice  of  physician  by  insured. 

3.  District  medical  officers  engaged  for  the  treatment  of  insured 
persons  in  prescribed  area^. 

4.  A  combination  of  above  methods. 

The  method  of^  compensation  for  medical  service  is  not  prescribed. 
Medical  officers  must  be  employed  by  the  carriers  to  certify  to  claims  and 
to  supervise  the  character  of  the  medical  service.  _  Arbitration  com- 
mittees, both  state  and  local,  to  be  composed  of  the  various  interests,  are 
provided  to  adjust  disputes  between  the  insured  and  the  physician  or 
between  the  fund  and  the  physicians. 

There  is  to  be  a  Social  Insurance  Commission,  one  member  of  which 
shall  be  a  physician,  to  carry  out  the  provision  of  the  act.  This  Com- 
mission is  to  be  advised  by  a  Social  Insurance  Council,  consisting  of 
employers  and  employees.  A  Medical  Advisory  Board,  chosen  by  the 
state  medical  societies,  is  to  be  consulted  on  medical  matters  and  is  to 
have  the  right  to  review  disputes  regarding  medical  matters  which  have 
been  appealed  to  the  Commisson.^^ 

The  above  bill  is  termed  a  "tentative  draft"  and  has  been  modi- 
fied in  some  respects.  The  bill  as  submitted  to  the  Conference  on  Social 
Insurance,  December  1916,  was  more  specific.^*  The  medical  organi- 
zation is  much  more  complete,  _due_to  the  cooperation  of  the  Social  In- 
surance Committee  of  the  American  Medical  Association.- 

In  addition  to  the  local  arbitration  committees,  there  are  created 
Local  Medical  Committees,  elected  by  the  physicians.  "To  this  com- 
mittee come  all  the  disputes  in  regard  to  medical  benefit  or  any  charge 
made  a^inst  a  physician  because  of  his  work,  before  it  is  sent  on  to 
the  board  of  directors  of  the  fund."^^ 

Public  health  officials  are  given  a  place  both  on  the  Local  Medical 
Committee  and  on  the  State  Medical  Advisory  Board,  so  that  the  neces- 
sity for  sanitation  and  preventive  medicine  may  not  be  lost  sight  of. 
A  State  Nurses'  Advisorv  Board  is  also  added. 

In  all,  the  American  Association  for  Labor  Legislation  has  pub- 
lished in  1915  and  1916  three  successive  drafts  of  the  Standard  Bill, 
and  as  a  result  of  further  suggestions  and  deliberations  by  its  Com- 
mittee on  Social  Insurance,  has  adopted  in  lieu  of  a  fourth  tentative 
draft,  the  provisions-  of  the  Nicoll  Bill  introduced  in  the  l^ew  York 
Legislature  in  1918  and  discussed  below. 

Other  Proposals. 

The  California  Commission,  while  it  approved  of  the  principle  of 
compulsory  health  insurance,  rejected  two  of  the  items  in  the  plan  of  the 
American  x\ssociation  for  Labor  Legislation.  The  Commission  be- 
lieved that  only  insurance  for  medical  benefits  should  be  in  a  prescribed 
carrier  and  that  the  cash  benefits  should  be  furnished  by  voluntary 
insurance  carriers.     It  also  disapproved  of  placing  the  administration 

33  For  more  detailed  information,  see  The  American  Labor  Legislation  Review, 
Vol.  VI,  No.  2. 

3*U.  S.  Bureau  of  Labor  Statistics,  Bulletin  212,  1917,  p.  663. 
35  Ibid.,  p.  647. 


636 

80  largely  in  the  hands  of  local  committees,  composed  of  employers  and 
employees,  believing  that  there  would  be  too  much  friction  and  that 
there  could  be  no  assurance  that  the  local  officials  possessed  the  neces- 
sary ability. 

The  Commission  would  still  have  state  and  local  advisory  boards, 
to  allow  for  representation  of  interests.  The  administration,  however, 
would  be  centralized  in  the  State  Commission  created  to  carry  out  the 
provisions  of  the  law. 

Under  the  California  plan,  a  state  fund  would  be  established,  which 
would  be  practically  the  only  carrier  providing  medical  benefits,  only 
trade  and  establishment  funds  being  allowed  to  carry  their  own  medical 
benefits.  This  fund  would  also  provide  cash  benefits  to  those  who  cared 
to  insure  in  it  rather  than  in  a  voluntary  association.  Under  this  plan, 
the  entire  contribution  to  the  state  fund  would  be  borne  by  the  employers 
and  the  state. 

The  medical  organization  under  this  scheme  would  consist  of  local 
panels,  including  all  licensed  physicians,  under  the  supervision  of  district 
medical  inspectors. 

The  Nicoll  Bill,  introduced  in  the  N^ew  York  legislature  in  Febru- 
ary, 1918,  has  been  endorsed  and  widely  distributed  by  the  American 
Association  for  Labor  Legislation  in  lieu  of  a  forth  edition  of  its  tenta- 
tive draft  of  a  Standard  Bill.This  bill  differs  in  some  important  particu- 
lars from  the  draft  of  the  Standard  Bill  discussed  above.This  bill,  which 
is  fostered  by  the  New  York  State  Federation  of  Labor,  excludes  volun- 
tary insurance  carriers  (except  establishment  funds)  from  the  system. 
This  was  not  because  the  Federation  was  opposed  to  voluntary,  insurance 
carriers,  but  because  it  believed  that  the  system  would  operate  more 
ouccessfully,  if  these  societies  were  allowed  to  supplement  the  compul- 
sory system  in  furnishing  additional  benefits  over  and  above  those 
allowed  under  the  compulsory  system.^^ 

The  Committee  on  Health  appointed  by  the  New  York  State 
Federation  felt  that  it  would  be  difficult  for  the  fraternal  associations 
and  trade  unions  to  rearrange  their  rates  so  as  to  provide  the  benefits 
required  by  the  act.  Consequently,  they  introduced  the  important 
modification  of  a  very  low  cash  benefit  to  be  paid  under  the  compulsory 
scheme,  so  that  opportunity  might  be  left  for  fraternals  and  trade 
unions  to  furnish  mainly  the  cash  benefits,  leaving  the  medical  and 
hospital  treatment  to  the  compulsory  system.  Under  this  proposed 
arrangement,  the  functions  of  fraternals  and  trade  unions  would  be  the 

_^  ••Pamphlet,  Official  Endorsement  of  New  York  State  Federation  of  Labor,  1918. 
The  Committee  on  Health  to  date  has  issued  five  reports :  the  one  just  referred  to ; 
a  second,  Diacuaaion  of  Bill  Endorsed  by  New  York  State  Federation  of  Labor;  a 
third,  Advantagea  to  Industry;  a  fourth,  A  Demand  for  the  Passage  of  a  Health 
Insurance  Law ;  a  fifth.  Progress  Toward  Health  Insurance  Legislation.  The  mem- 
bers of  this  committee  are:  James  M.  Lynch,  formerly  President  of  the  Internat- 
ional Typographical  Union  and  now  chairman  of  the  Industrial  Commission  of  New 
York  ;  William  Rander.  organizer  for  the  Brotherhood  of  Painters  and  Decorators ; 
'^?^Ji  ^^^  ^^I'^'ll*?"'  '"^^J",^^  of  the  Troy  Typographical  Union  ;  Charles  H.  Stevens 
^J^^  Buffalo  Cigar  Makers;  Richard  H.  Curran  of  the  Rochester  Holders;  Nellie 
Kelly  of  the  United  Qament  Workers;  Rose  Schneiderman  of  the  Women's  Trade 
Union  League  ;  James  P.  Boyle  of  the-  Brooklyn  Bookkeepers',  Stenographers'  and 
Accountants  Union;  and  Roswell  D.  Tompkins,  secretary  of  the  New  York  United 
Board  of  Business  Agrents. 


637 

providing   of    additional   cash   benefits,   while   the   compulsory   scheme 
would  provide  the  minimum  medical  and  cash  benefits. 

In  the  Nicoll  Bill,  the  insurance  is  made  compulsory  for  all  em- 
ployees, the  cash  contribution  by  the  state  is  eliminated,  and  the  con- 
tribution by  the  employer  and  the  employee  are  made  equal.  The 
decision  to  eliminate  the  contribution  by  the  state  is  interesting,  be- 
cause some  labor  organizations  object  to  any  contribution  on  the  part  of 
the  employee.  Of  twenty-two  labor  representatives  who  testified  before 
the  Massachusetts  Commission  on  Social  Insurance,  which  reported 
January  15,  1918,  all  were  in  favor  of  some  form  of  health  insurance, 
but  only  one  cared  to  go  on  record  as  favoring  a  contributory  plan.  The 
State  Federation  of  Massachusetts  also  declared  for  a  non-contributory 
system. 

Attitude  of  Organized  Labor. 

It  will  be  seen  that  the  Xew  York  State  Federation  of  Labor  has 
taken  a  definitely  aggressive  position  in  favor  of  a  plan  of  compulsory 
health  insurance,  drafted  bv  its  own  committee  as  a  modification  of  the 
"Standard  Bill.^'  Outside  New  York,  organized  Labor  has  not  studied 
the  subject  long  enough  to  have  committed  itself  definitely  either  for  or 
against  compulsory  health  insurance.  The  official  attitude  of  individual 
unions,  as  expressed  in  the  form  of  resolutions,  sometimes  depends  upon 
the  opinion  of  whoever  happened  to  present  the  resolution.  Not  being 
immediately  concerned  with  the  subject,  the  resolution  may  be  passed 
without  close  scrutiny.  A  case  in  point  is  that  of  the  International 
Typographical  Union.  At  its  Scranton  metting,  in  August  1918,  two 
conflicting  resolutions  were  introduced.  The  first  resolution  favored 
the  inclusion  of  occupational  diseases  in  workmen^s  compensation  laws 
(proposition  72)  but  was  opposed  to  health  insurance,  saying: 

"*  *  *  the  system  of  health  insurance  is  advocated  mainly  by 
socialists  and  theorists,  who,  for  the  most  part  are  not  affiliated  with  the 
labor  movement.'^ 

The  second  resolution  favoring  health  insurance  (proposition  118) 
was  adopted  later  in  the  session  and  carried  this  clause : 

"Resolved,  That  the  Scranton  Convention  of  the  International  Typo- 
graphical Union  herewith  endorse  health  insurance  for  wage-earners 
and  their  dependents,  with  equal  contributions  from  employers  and 
employees,  the  funds  democratically  administered." 

The  Executive  Council  of  tlie  American  Federation  of  Labor  has 
been  distinctly  opposed  to  compulsory  health  insurance,  but  has  favored 
investigation  of  its  merits.^^  This  appears  from  the  annual  reports 
made  by  the  Council  to  the  Annual  Conventions  of  the  Federation.  In 
1915,  the  report  contained  the  following  clause  :^^ 

3^  The  Executive  Council  is  elected  at  the  Annual  Conventions  of  the  American 
Federation  of  Labor,  and,  for  the  year  1917-18,  was  composed  as  follows:  Samuel 
Gompers,  James  Duncan,  James  O'Connell,  Jos.  F.  Valentine,  John  R.  Alpine,  H.  P. 
Perham,  Frank  Duffy,  William  Green,  W.  D.  Mahon,  Daniel  J.  Tobin,  Frank  Mor- 
rison. At  the  Convention  in  1918,  T.  A.  Rickert  and  Jacob  Fischer  were  substituted 
for  James  O'Connell  and  H.  P.  Perham. 

^  Report  of  the  Proceedings  of  the  Thirty-sixth  Annuai  Convention  of  the 
American  Federation  of  Labor,  Baltimore,  1916,  p.  145. 


( 


638 

"We  strongly  recommend  that  the  subject  of  social  insurance  in  all 
its  phases  be  given  greater  consideration  and  extension  by  the  unions 
and  preferentially  by  the  national  and  international  unions,  as  well  as 
by  the  local  unions,  and  in  any  event,  in  so  far  as  social  insurance  by  the 
state  and  national  governments  is  concerned,  if  established  at  all,  shall 
be  voluntary  and  not  compulsory/' 

In  its  Report  to  the  Convention  at  St.  Paul  in  June,  1918,  the 
Executive  Council  made  the  following  comment  and  recommendation  :^^ 

"The  organized  labor  movement  approved  the  enactment  of  work- 
men's compensation  legislation.  Their  approval  of  that  legislation  was 
based  upon  the  theory  that  when  the  earning  power  of  a  worker  was 
impaired  by  reason  of  an  industrial  accident,  that  he  or  his  dependents 
should  be  compensated  during  the  time  he  was  suffering  from  said  injury. 
The  same  rule  holds  good  when  the  worker  becomes  incapacitated  through 
illness — particularly  illness  due  to  trade  or  occupation.  He  and  his 
family  suffer  through  the  impairment  of  his  earning  power  just  the  same 
when  he  is  ill  as  when  he  sustains  an  injury.  The  organized  labor 
movement  of  America  ought  to  formulate  a  program  upon  this  subject. 

"We  therefore  recommend  to  this  convention  that  it  authorize  the 
Executive  Council  of  the  American  Federation  of  Labor  to  make  an  in- 
.vetigation  into  the  subject  of  Health  Insurance,  particularly  as  it 
applies  to  trade  or"  occupational  disease.  If  approved  a  model  bill  be 
formulated  and  reported  to  the  A.  F.  of  L.  for  approval.  We  urge  that 
as  part  of  such  legislation  there  should  be  embodied  fundamental  princi- 
ples of  democratic  administration  and  guarantee  to  the  workers  of  an 
equal   voice  and  equal  authority  in  the  administration  of  all  its  features. 

"It  was  decided  that  the  E.  C.  recommend  to  the  convention  that  it 
authorize  the  E.  C.  to  appoint  a  committee  to  make  a  study  and  report 
on  the  desirability  of  enacting  laws  providing  for  the  payment  of  sick 
benefits  .during  time  of  illness.'' 

The  Annual  Convention  of  the  American  Federation  of  Labor  is 
composed  of  delegates  from  the  national  and  international  trade  unions  * 
and  from  state  federations  and  certain  local  labor  federations.  The 
number  of  delegates  in  1918  was  448.  At  the  Baltimore  Convention, 
1916,  the  Convention  unanimously  approved  the  recommendation  of  its 
Executive  Council,  as  quoted  above,  in  opposition  to  compulsory  social 
insurance.     It  also  passed  this  resolution : 

"Resolved,  That  the  American  Federation  of  Labor  ir.  Thirty-sixth 
Annual  Convention  assembled,  declares  against  private  insurance  or 
insurance  for  profit,  as  it  may  apply  to  industrial,  social  or  health 
insurance."*^ 

At  the  Convention  in  1918  a  resolution  introduced  from  the  floor 
and  approving  "a  comprehensive  national  svstem  of  social  insurance" 
was  voted  down  on  the  ground  that  it  did.  not  provide  for  the  investi- 
gations which  "should  necessarily  precede  a  definite  conclusion  or  pro- 
gram  on  the  subject."     The  Convention,  at  the  same  time,  approved  the 

^1^-w^^'"^^^^  *^^   Pj'oceedings   of   the    Thirty -eighth   Annual    Convention    of    the 
American  Federation  of  Labor,  St.  Paul.  1918,  p   94 

A^ll.?P%^ A^^  }^^    P/oce^tiings    of    the    Thirty-sixth    Annual    Convention    of    the 
American  Federation  of  Labor,  Baltimore,  1916,  p.  216. 


639 

recommendation  of  the  Executive  Council  above  quoted^  and  instructed 
tlie  Council  to  make  the  investigation.*^ 

Through  inquiries  made  by  correspondence  with  the  secretaries  of 
labor  organizations,  it  has  been  found  that  the  following  national  and 
international  unions  have  placed  themselves  on  record  as  favoring  com- 
pulsory health  insurance:  Brotherhood  of  Kailway  Carmen  of  America; 
Journeymen  Stone  Cutters'  Association;  International  Brotherhood  of 
Pulp,  Sulphite  and  Paper  Mill  Workers  of  the  United  States  and  Canada; 
International  Fur  Workers'  Union  of  the  United  States  and  Canada; 
International  Ladies'  Garment  Workers'  Union;  International  Seamen's 
Union;  International  Stereotypers'  and  Electrotypers'  Union  of  ^orth 
America;  International  Union  of  Steam  and  Operating  Engineers;  Inter- 
national Union  of  Mine,  Mill  and  Smelter  Workers ;  International  Typo- 
graphical Union;  National  Women's  Trade  Union  League;  and  United 
Brewery,  Flour,  Cereal  and  Soft  Drink  Workers  of  America.  Sixty- 
two  secretaries  of  national  and  international  unions  replied  that  no 
action  had  been  taken  by  their  organizations.  The  Brotherhood  of 
Locomotive  Enofineers  was  the  onlv  national  or  international  union  that 
reported  having'  passed  a  resolution  against  compulsory  health  insur- 
ance.^- In  addition  to  the  above,  the  Xew  York  State  Federation  of 
Labor  reports  the  following  national  and  international  unions  as  favor- 
ing compulsory  health  insurance:  American  Wire  Weavers^  Protective 
Association;  International  Glove  Workers'  Union  of  America;  Spin- 
ners' International  Union ;  Eetail  Clerks'  International  Protective  Asso- 
ciation. 

Correspondence  Avith  the  secretaries  of  State  Federations  of  Labor 
furnishes  the  following  list  as  favoring  compulsor}^  health  insurance :. 
The  State  Federations  of  Labor  in  Arkansas,  California,  Colorado, 
Indiana,  Massachusetts,  Minnesota,  Missouri,  Xew  York^  Pennsylvania, 
and  Wisconsin.  There  were  ten  State  Federations  that  reported  no 
action  taken.  Xone  reported  having  passed  a  resolution  against  com- 
pulsory health  insurance.  The  New  York  State  Federation  of  Labor 
reports  these  additional  State  Federations  as  favorable  to  compulsory 
Health  insurance."*^  State  Federations  of  Labor  in  Alabama,  Con- 
necticut, Marvland,  District  of  Columbia,  Illinois,  New  Jersev  and  West 
Virginia. 

Whatever  opposition  to  compulsoiy  health  insurance  exists  on  the 
part  of  organized  labor  arises  partly  from  the  belief  that  such  a  measure 
might  undermine  union  activity  and  prove  to  be  only  a  palliative  and  > 
a  substitute  for  better  wages,  hours  and  conditions  of  labor.     Thus,  ' 
Samuel  Gompers,  President  of  the  American  Federation  of  Labor,  has 
said  :** 


<i  Report  of  the  Proceedings  of  the  Thirti/-ni7ith  Annual  Convention  of  the 
American  Federation  of  Labor,  St.  Paul,  1918,  p.  283.  The  special  committee  to 
Investigate  health  insurance  has  recently  been  appointed  with  John  A.  Voll,  Presi- 
dent of  the  Glass  Blowers'  Association,  as  chairman. 

"/See  p.  15,  First  Report  of  the  Committee  on  Health,  and  p.  S,  Fifth  Report 
of  the  same  committee. 

*^  See  p.  15,  First  Report  of  the  Committee  on  Health,  and  p.  6,  Fifth  Report 
of  the  same  committee. 

"  Address  at  the  Seventeenth  Annual  Meeting  of  the  National  Civic  Federation, 
January  22,  1917. 


640 

"This  fundamental  fact  stands  out  paramount,  that  social  insur- 
ance cannot  remove  or  prevent  poverty.  It  does  not  get  at  the  causes 
of  social  injustice     *     *     *. 

"The  efforts  of  trade  organizations  are  directed  at  fundamental 
things.  They  endeavor  to  secure  to  all  the  workers  a  living  wage  that 
<will  enable  them  to  have  sanitary  homes,  conditions  of  living  that  are 
conductive  to  health,  adequate  clothing,  nourishing  food  and  other 
things  that  are  essential  to  the  maintenance  of  good  health. 

"In  attacking  the  health  problem  from  the  preventive  and  con- 
?li  UL-tive  side  they  are  doing  infinitely  more  than  any  health  insurance 
could  do  which  provides  only  for  relief  in  case  of  sickness,  and  yet  the 
compulsory  law  would  undermine  union  activity. 

"There  would  necessarily  be  a  weakening  of  independence  of  spirit 
and  virilit}',  when  compulsory  insurance  is  provided  for  so  large  a  num- 
ber of  citizens  of  the  state.'' 

Attitude  of  Employers. 

In  addition  to  the  general  arguments  before  mentioned,  employers 
have  pointed  out  that  the  initial  expense  of  insurance  could  not  be 
absorbed  in  the  cost  of  production  and  shifted  to  consumers.  They 
also  feel  that,  if  such  a  law  is  not  uniform  throughout  the  United 
States,  it  will  place  employers  in  states  which  adopt  it  at  a  disadvantage 
in  competition  with  those  of  other  states.  The  Associated  Manu- 
facturers and  Merchants  of  Isew  York  State,  with  headquarters  at 
Buffalo,  are  conducting  a  strong  fight  against  it  in  that  state.  Their 
arguments  are  presented  in  a  monthly  bulletin,  "The  Monitor." 

The  National  Industrial  Conference  Board,  headquarters  at  Boston, 
composed  of  national  associations  of  employers,*^  has  issued  a  series 
of  pamphlets  tending  to  show  that  sickness  prevention  rather  than  sick- 
ness insurance  is  the  thing  to  be  desired.  It  has  had  representatives  at 
various  legislative  hearings  and  in  California  during  the  recent  referen- 
dum on  the  proposed  social  insurance  amendment  to  the  constitution. 

The  Illinois  Manufacturers'  Association  in  a  memorandum  addressed 
to  the  Commission  on  Health  Insurance  of  the  State  of  Illinois  set 
forth  their  position  as  follows: 

"We  respectfully  submit  that  the  responsibility  and  cost  of  illness 
among  those  employed  in  industry  should  be  apportioned  as  follows  : 

1.  The  cost  of  disability  due  to  strictly  occupational  diseases  should 
be  borne  entirely  by  the  employer  and  the  amount  and  manner  of  com- 
pension  may  properly  be  fixed  by  the  Workmen's  Compensation  Law. 

2.  If  Illinois  sees  fit  to  adopt  a  program  of  Social  Insurance,  then 
the  portion  of  the  cost  which  the  beneficiaries  themselves  cannot  bear 
may  possibly  be  assumed  by  the  citizens  and  taxpayers  of  the  State, 

iiji^r.T,^V^^^^^'A  American  Cotton  Manufacturers'  Association;  American  Hardware 
,,#'t!^l^™P.  ^1  Association  ;  American  Paper  and  Pulp  Association  ;  Electrical  Man- 
I!>«oi  a«L,?!H?  •  ^*^%"^!^^^M^^"^  Chemists'  Association  of  the  United  States  :  Nsit- 
mohIA^i  A  oc.  «.  /?£  Cotton  ISIanufacturers  ;  National  Association  of  Manufacturers ; 
?ni^o^L^^^°„^».^^'°V  T?^  ^^''l  ^Manufacturers ;  National  Automobile  Chamber  of 
?f^I?3i^ri;.5o?^  T^^"^'  ^°St  *^"*^  ^^^^  Manufacturers'  Association  :  National  Council 
^.«Hnn"  M^L^t^^"^  V  ?^*.l^°"^^  Erectors'  Association ;  National  Founders'  Asso- 
?lnorn«'roJl^i  2mI  ¥^}^\  J""^^^!  Association;  Rubber  Association  of  America, 
Incorporated .   Silk  Association  of  America  ;  United  Typothetae  of  America. 


641 

but  no  employer  should  he  assessed  therefor  in  any  greater  degree  than 
he  would  be  for  any  other  burden  that  falls  generally  upon  the  com- 
munity. 

The  National  Association  of  Manufacturers  has  not  taken  any 
positive  action  for  or  against  compulsory  health  insurance,  although  ^ 
it  has  had  a  committee  investigating  the  subject  since  1915.  At  its 
Annual  Convention  in  that  year  it  approved  of  the  appointment  of  a 
Committee  on  Industrial  Betterment,  to  study  the  problems  of  social 
legislation;  particularly,  the  questions  of  the  minimum  wage,  insur- 
ance against  sickness,  and  unemployment.  This  Committee  stated  in 
its  1916  report  that  "sickness  insurance  should  be  made  to  cover 
workers  independent  of  whether  the  cause  of  the  sickness  arose  out  of  or 
in  the  course  of  employment.  The  report  also  stated  that,  "The  plan 
must  contain  the  elements  of  compulsion,  direct  or  indirect,  as  a  matter 
of  expediency  in  securing  the  acceptance  of  the  act,"*^ 

The  Committee  on  Industrial  Betterment  for  the  year  1916-1917 
had  a  slightly  different  personnel,  William  P.  White  replacing^  F.  C.      i. 
Schwedtman,  as  chairman.     Its  report  at  the  1917  Convention  carried 
the  following  paragraph  :^" 

"Your  Committee  is  not  convinced  from  its  study  of  the  available 
data  on  the  subject  that  the  creation,  establishment,  and  operations  of 
a  state-goverened  system  of  compulsory  sickness  insurance  is  either 
necessary,  wise,  or  desirable." 

The  report  of  the  Committee  on  Industrial  Betterment  for  1917- 
1918  contained  the  following  statements:*^ 

"Sickness  is  not  only  a  problem  for  the  community  as  a  whole,, 
to  be  treated  as  an  administrative  function  of  the  State,  but  it  is  also  a 
problem  arising  out  of  industry." 

*Tt  would  seem  to  your  Committee  that,  prior  to  the  consideration 
of  a  compulsory  form  of  industrial  sickness  insurance,  the  question 
of  voluntary  insurance  should  be  carefully  reviewed,  especially  the  study 
of  the  existing  systems  ^n  operation  in  many  of  our  industrial  and 
transportation  companies. 

"The  Massachusetts  Commission  on  Social  Insurance  has  declared 
itself  to  be  ^unanimously  of  the  opinion  that  the  principle  of  insur- 
ance is  a  desirable  one  for  application  on  a  sufficiently  wide  scale  to 
safeguard  every  wage  earner  in  the  Commonw^ealth  from  certain  of  the 
evils  of  sickness  *  *  *.'  With  this  principle  your  Committee 
thoroughly  agrees,  for  insurance  is  the  proper  method  to  distribute  the 
losses  of  sickness,  and  is  so  generally  recognized." 

"We  hazard  the  opinion  that  unless  sickness  insurance  is  demo- 
cratically administered,  equitably  worked  out,  and  extended  to  cover 
practically  all  kinds  of  wage  workers,  there  will  be  enacted  into  law 
compulsor}'  sickness  insurance — a  proceeding  which  your  Committee  at 
the  present  time  feels  would  be  some  reflection  on  the  high  standards 

*' Proceedings  of  Twenty-first  Annual  Convention  of  the  National  Association 
of  Manufacturers,  1916.  pp.   33-39. 

*''  Proceedings  of  the  Twenty-second  Annual  Convention  of  the  National  Asso- 
ciation of  Manufacturers,  1917,  p.  21. 

**  Proceedings  of  the  Twenty-third  Annual  Convention  of  the  National  Asso- 
ciation of  Manufacturers,  1918,  p.   162-164. 

—41  H  I 


642 

of  industrial  conduct  which  characterize  the  safeguarding  of  American 

workers." 

None  of  the  above  reports  were  adopted;  they  were  accepted  and 

ordered  printed. 

Attitude  of  Medical  Profession. 

The  Board  of  Trustees  of  the  American  Medical  Association  ap- 
pointed in  January  1916  a  special  committee  to  investigate  social  in- 
surance. This  committee  issued  a  series  of  pamphlets,  dealing  chiefly 
with  health  insurance.  In  June  1917,  the  House  of  Delegates  of  the 
American  Medical  Association  passed  a  resolution  encouraging  further 
work  on  the  subject  and  instructing  its  Council  on  Health  and  Public 
Instruction  to  cooperate  when  posssible  "in  the  molding  of  these  laws 
that  the  health  of  the  community  may  be  properly  safeguarded  and  the 
interests  of  the  medical  profession  protected^^  and  to  "insist  that  such 
legislation  shall  provide  for  freedom  of  choice  of  physicians  by  the 
insured;  payment  of  the  physician  in  proportion  to  the  amount  of  work 
done;  the  separation  of  the  function  of  medical  officials  supervision 
from  the  function  of  daily  care  of  the  sick;  and  the  adequate  repre- 
sentation of  the  medical  profession  on  the  appropriate  administrative 
bodies." 

This  resolution,  it  will  be  noted,  is  neither  for  nor  against  com- 
pulsory health  insurance  and  is  the  only  resolution  on  the  subject 
ever  passed  by  the  House  of  Delegates  of  the  American  Medical  Asso- 
■ciation.  The  medical  organization  proposed  in  the  Standard  Bill  is 
in  harmony  with  this  resolution.  This  would  necessarily  be  so,  since 
the  Committee  on  Social  Insurance  which  presented  the  resolution  to 
the  Medical  Association  for  approval  was  represented  by  Dr.  Alexander 
Lambert  on  the  Committee  of  the  Association  for  Labor  Legislation 
which  drafted  the  provisions  of  the  Standard  Bill.   - 

The  state  medical  associations,  for  the  most  part,  have  taken  no 
action  in  the  matter.  Of  thirty-four  state  associations  replying  to 
questionnaires,  thirty-one  had  not  gone  on  record;  one  (Wisconsin)  had 
passed  a  resolution  favoring  the  principle  of  compulsory  health  insur- 
ance; and  two  (Illinois  and  Delaware)  has  passed  a  resolution  opposing 
it.  In  New  York,  the  Chairman  of  the  Committees  on  Legislation  and 
Economics  of  the  State  Medical  Society  appeared  before  the  Judiciary 
Committee  of  the  State  Senate  to  oppose  the  Nicoll  Bill.  Dr.  H.  L. 
Winter,  Chairman  of  the  Committee  on  Economics,  stated  that  he  had 
communicated  with  all  the  county  medical  societies  in  the  state  and  that 
they. were  unanimously  opposed  to  the  bill. 

At  the  Second  Annual  Meeting  of  the  American  Association  of 
Industrial  Physicians  and  Surgeons  in  1917,  including  mainly  mem- 
bers of  the  profession  employed  by  corporations^  the  report  of  the  Com- 
mittee on  Health  Insurance  which  stated  "that  the  principle  of  health 
insurance  which  makes  proper  provision  for  the  prevention  of  sickness 
as  well  as  proper  provision  for  the  relief  of  sickness  is  a  sound  one" 
was  unanimously  adopted.  Tliis  resolution  had  reference  to  compulsory 
health  insurance 


643 

Public  health  physiciaoSj,  while  they  seem  generally  to  favor  the 
establishment  of  governmental  systems  of  health  insurance,  believe 
"That  in  any  scheme  for  health  insurance,  all  activities  looking  toward 
the  active  conservation  and  promotion  of  health  should  be  entrusted  to 
the  regularly  established  health  conservation  agencies,  which  should  be 
reorganized  or  reinforced  for  that  purpose,  if  necessary."*^ 

Dr.  B.  S.  Warren,  of  the  United  States  Public  Health  Service 
would  have  the  state  health  commissioner  made  a  member  of  the  health 
insurance  Commission.  He  would  also  have  the  referees  who  supervise 
the  medical  benefits,  in  the  employ  of  the  health  department.  It  is 
doubtful  whether  the  medical  profession  would  submit  to  this  control. 

As  with  the  physicians,  all  the  other  interests  affected:  nurses, 
dentists,  druggists,  oculists,  and  hospitals,  demand  that  they  shall  be 
represented.  The  public  health  nurses  do  not  object  to  the  scheme,  if 
we  may  take  as  representative  the  sentiments  expressed  by  Mary  Beard, 
President  of  the  National  Organization  for  Public  Health  Nursing: 
"We  public  health  nurses  have  more  conclusive  evidence  than  any  other 
group  in  America  (of  the  need  of  health  insurance)  *  *  *  Health 
insurance  is  advancing  more  and  more  certainly."^^ 

The  American  Hospital  Association  at  its  meeting^  September  27, 
1918,  adopted  this  resolution: 

'^Resolved,  By  the  American  Hospital  Association  that  the  im- 
portance of  health  insurance  investigation  be  recognized  by  this  body 
and  the  Board  of  Trustees  be  directed  to  make  a  study  of  the  subject  in  its 
relation  to  the  hospitals  and  dispensaries;  that  the  Board  of  Trustees  give 
such  assistance  as  may  be  requested  in  the  formulation  of  plans  and  of 
legislative  bills ;  that  the  members  of  this  Asociation  and .  the  State 
Hospital  Association  be  urged  to  give  the  subject  careful  study  and  to 
cooperate  wherever  possible  in  the  effective  solution  of  the  problems 
unsolved.'^ 

Attitude  of  Druggists. 

In  as  much  as  compulsory  health  insurance  will  mean  more  or  less 
wholesale  distribution  of  drugs,  it  would  be  expected  that  druggists 
would  not  take  kindly  to  the  plan.  The  American  Pharmaceutical 
Association  passed  the  following  resolution  at  its  1917  convention: 

"The  American  Pharmaceutical  Association  desires  to  express  its 
disapproval  of  the  Compulsory  Health  Insurance  Bills  introduced  in 
different  state  legislatures  during  the  past  winter.  It  is  quite  likely 
that,  in  the  interests  of  wage-earners  of  very  limited  income  some- 
thing in  the  way  of  social  insurance  should  be  provided  under  the  super- 
vision of  the  state,  but  the  present  plan  goes  much  too  far  and  is  open 
to  many  vital  objections.'^ 

The  National  Association  of  Retail  Druggists  at  its  1918  convention 
passed  this  resolution : 

**  Resolution  adopted  at  the  Fifteenth  Annual  Conference  of  State  and  Territorial 
Health  Officers  with  the  U.  S.  Public  Health  Service,  1917. 

^"  Quoted  in  the  Fifth  Report  of  the  Committee  on  Health  of  the  New  York 
Federation  of  Labor. 


644 

"Whereas,  The  Proponents  of  compulsory  health  insurance  con- 
tinue their  activities  in  an  effort  to  force  such  a  measure  upon  the  people 

of  the  several  states,  and 

"Whereas,  We  believe  such  Prussianized  le^slation  to  be  inimical 
to  the  practice  of  pharmacy ;  thereTore  be  it 

Resolved,  That  the  National  Association  of  Eetail  Druggists  be 
and  hereby  is  requested  to  reiterate  its  opposition  to  such  obnoxious 
measures  and  to  lend  its  assistance  to  the  pharmacists  of  the  various 
states  in  their  efforts  to  prevent  the  enactment  of  compulsorv^  health 
inpurance  laws." 

The  "floating  six-pence"  of  the  British  Health  Insurance  Act^  a 
plan  whereby  the  physicians'  fund  benefits  by  reduction  in  the  amount 
of  drugs  prescribed,  is  responsible  for  much  of  the  hostile  feeling  on  the 
part  of  druggists. 

Attitude  of  Insurance  Companies. 

The  interest  most  deeply  affected  adversely  by  compulsory  health 
insuran|ce  would  be  the  commercial  insurance  compan}'.  The  majority 
of  labor  organizations  that  have  gone  on  record  as  favoring  health 
insurance,  declare  themselves  opposed  to  commercial  insurance  carriers. 
The  plan  submitted  by  the  American  Association  for  Labor  Legislation 
likewise  excludes  the  commercial  insurance  carriers.  The  industrial 
insurance  companies  w^ould  suffer  most  of  all,  since  they  in  reality 
supply  what  amounts  to  burial  insurance.  The  Insurance  Year-Book  for 
1918  states  that  industrial  insurance  companies  have  issued  38,373,272 
industrial  policies  in  the  amount  of  $5,193,830,295.  The  average  policy 
is  tlierefore  about  $138.  The  casualty  companies  would  be  affected 
somewhat,  but  their  business  is  not  so  directly  connected  with  wage- 
earners. 

The  commercial  insurance  companies  are  conducting  a  well  organized 
and  extensive  propaganda  against  compulsory  health  insurance.  Per- 
Iiaps  tlic  most  pronounced  opponent  of  compulsory  health  insurance  is 
Br.  Frederick  L  .  Hoffman,  Statistician  and  Third  Vice-President  of 
the  Prudential  Insurance  Company.  His  pamphlet,  "Facts  and  Fallacies 
of  Compulsory  Health  Insurance"  published  by  the  Pmdential  Press, 
Newark,  N.  J.,  has  been  widely  distributed  and  forms  a  large  part  of  the 
arguments  and  statistical  data  of  the  opponents  of  compulsory  health 
insurance. 

P.  Tecumseh  Sherman,  New  York  attorney  and  former  Commis- 
sioner of  Ubor  of  that  state,  has  issued  a  pamphlet,  "Criticism  of  a 
Tentative  Draft  of  an  Act  for  Health  Insurance."  Mr.  Sherman  fre- 
quently appears  at  legislative  hearings  as  counsel  for  insurance  companies. 

The  fraternal  insurance  associations  also  feel  that  their  interests 
would  suffer.  At  the  National  Fraternal  Congress  of  America  1918, 
it  was  resolved  "That  the  constituent  societies  of  the  Congress  use  all 
honorable  means  to  prevent  the  enactment  into  law  in  any  form  of  a 
plan  for  social  insurance  through  ^tate  or  National  control." 

Other  propaganda  agencies  supporting  the  insurance  companies 
are:     The  Workmen's  Compensation  Publicity   Bureau    (New    York), 


645 

The  Insurance  Economics  Society  of  America  (Detroit),  and  the  Cali- 
fornia Research  Society  of  Social  Economics   (Los  Angeles). 

Attitude  of  Other  Interests  Affected. 

Most  of  the  foregoing  discussion  has  been  confined  to  an  analysis 
of  the  attitude  of  the  major  interests  directly  affected.  However,  there 
are  some  groui^s  and  associations;,  representing  interests  indirectly  affected 
or  which  arc  more  or  less  detached  interests,  which  should  be  mentioned. 

The  majority  of  charity  workers  seem  to  favor  compulsory  health 
insurance.  Eugene  T.  Lies,  until  recently  Superintendent  of  the  United 
Charities,  Chicago,  believes  "Health  Insurance  would  bring  to  wage- 
earners  prompt  medical  care,  cash  benefits  to  tide  them  and  give  them 
an  early  chance  for  recovery,  all  for  a  small  insurance  premium."^^ 
J.  W.  Magmder,  general  secretary,  the  Federated  Charities,  Baltimore, 
Md.,  says  "The  charity  organizations,  however,  will  be  the  more  able  to 
accept  the  responsibility  for  the  relatively  small  group  of  unfortunates 
(not  covered  by  health  insurance. )^'^^ 

The  socialists  claim  to  .be  the  first  political  party  in  this  country  ^ 
to  adopt  a.  compulsory  insurance  plank.  The  Social  Democratic  party 
in  1900  .had  a  plank  providing  for  "I^ational  Insurance  of  working 
people  against  accident,  lack  of  employment  and  want  in  old  age."'  The 
1904  platform  of  the  Socialist  Party  carried  a  plank  "for  the  insurance 
of  the  workers  against  accident,  sickness  and  lack  of  employment ;  for 
pensions  for  aged  and  exhausted  workers."  The  1908  plans  added  death 
insurance.  The  1912  and  1916  platforms  had  the  following  provisions: 
^'X  general  system  of  insurance  by  the  state  of  all  its  members  against 
unemployment  and  invalidism  and  a  system  of  compulsory  insurance  by 
employers  of  their  workers  without  cost  to  the  latter,  against  industrial 
diseases,  accidents  and  death." 

Tlie-PxQgresaives_.W£re  the  second  national  party  to  endorse  health 
insurance,  declaring  in  the  1912  platform  for: 

"^  The  protection  of  home  life  against  hazards  of  sickness,  irregular 
employment  and  old  age  through  the  adoption  of  a  system  of  social 
insurance  adapted  to  American  use. 

ThejChristian  Scientists  are  opposed  to  compulsory  health  insur- 
ance because  they  believe  it  is  unjust  to  compel  them  to  contribute 
toward  the  support  of  a  system  which  is  repugnant  to  their  religious 
beliefs  and  from  which  they  can  receive  no  benefit.  They  played  an 
influential  part  in  the  defeat  of  the  California  Constitutional  Amend- 
ment. 

The  N'ational  Consumers'  League  at  its  recent  meeting  in  1918 
passed  the  following  resolution : 

Whereas,  The  wartime  experience  of  women  as  wage-earners  taking 
the  places  of  men  has  greatly  emphasized  the  need  of  compulsory  health 
insurance;  therefore  be  it 

"Resolved,  That  the  National  Consumers'  League  endorse  in  prin- 
ciple the  prompt  passage  of  health  insurance  by  the  state  legislatures." 

^'^Proceedings  of  National  Conference  of  Social  Work,  p.  552 
'^^U.  S.  Bureau  of  Labor  Statistics,  Bulletin  212,  p.  636. 


C46 


The  National  Civic  Federation,  which  is  designed  to  represent 
organized  labor,  organized  industry  and  the  general  public,  began  in 
1913  what  was  expected  to  be  a  five  year  investigation  of  social  insurance 
in  this  country  and  abroad.  The  Committee  on  Preliminary  Foreign 
Inquiry,  a  sub-committee  of  the  Social  Insurance  Department,  sub- 
mitted a  report  in  1914  covering  the  operation  of  social  insurance  in 
England.  Further  foreign  investigation  was  cut  short  by  the  war.  The 
report  on  England  on  the  whole  was  unfavorable  and  the  committee 
concluded  "that  the  entire  Aovement  as  it  has  thus  far  advanced  in 
England  is  still  too  young  to  afford  any  permanent  conclusions  upon  its 
human  or  social  economic  values.^'  The  members  of  this  committee 
were:  J.  W.  Sullivan,  representing  the  American  Federation  of  Labor; 
Arthur  Williams,  representing  employers;  P.  Tecumseh  Sherman,  At- 
torney and  Social  Insurance  Specialist.  Mr.  Sherman  has  been  men- 
tioned before  as  author  of  a  pamphlet  criticizing  the  Standard  Bill  and 
as  an  attorney  representing  insurance  companies. 

The  Social  Insurance  Department  of  the  National  Civic  Federation 
on  February  20,  1917,  published  the  following  resolution : 

"Resolved,  That  the  Social  Insurance  Department  of  the  National 
Civic  Federation,  composed  of  representatives  of  organized  labor,  organ- 
ized industry  and  the  interests  of  the  general  public,  emphatically  declare 
itself  opposed  to  the  contemplated  legislation  with  reference  to  com- 
pulsory health  insurance,  as  inimical  to  the  best  interests,  present  and 
future,  of  the  workers  of  the  nation."^^ 

A  month  before  this  resolution  was  adopted  the  annual  meeting 
of  the  National  Civic  Federation  had  been  held  under  the  auspices  of 
the  Social  Insurance  Depai-tment.  At  this  meeting,  which  was  devoted 
to  Compulsory'  Health  Insurance,  all  of  the  addresses  with  the  exception 
of  those  descripti^^  of  establishment  funds,  were  in  opposition. 

The  California  Referetidum. 

At  the  last  election  (November  1918)  there  was  submitted  to  the 
people  of  California  for  a  referendum  vote  an  amendment  to  the  state 
constitution,  which  was  designed  to  give  the  legislature  power  to  pass 
social  msurance  legislation.  This  amendment  had  been  offered  by  the 
Social  Insurance  Commission  whose  report  has  already  been  mentioned 
above.  The  amendment  failed  of  passage  by  a  vote  of  more  than  two 
to  one.  The  Christian  Scientists  are  said  to  ha^^  been  a  potent  factor 
in  bringing  about  this  result. 

In  addition  to  the  opposition  of  Christian  Scientists,  the  fraternal 
and  commercial  insurance  companies  assisted  in  defeating  the  amend- 
ment. Some  of  the  large  fraternal  organizations  sent  a  personal  com- 
munication to  each  of  their  members,  asking  that  they  vote  against  the 
amendment.     In  this  way  over  200,000  voters  are  said  to  have  been 

PWpr4d*b?%'hr£^iriX1v«^?^n?S^ttl^''^"^^"^^  Department.  Reprint  May  26.  1917, 
f?Sldlnt    of    Met7S?ol?«n    rSn^r^^  o^  Lee  K.   Frankel,   Third  Vice- 

jS^Sluonot^^Srlcu!l^^^^  chairman;    A.    Parker    NeVin,    National 

Ch5J?man   o?  the^oSarinSriinf^rf  ""^.^r^'  American  Federation  of  Labor.     The 
iSem'Suon^'  Brother'llSLd' of^Lo^c^mo'^^^^^^^  S-   ^tone.   Grand  Chief 


647 

reached.  The  Associated  Fraternal  Societies  of  California  also  issued 
literature  under  the  auspices  of  the  California  Eesearch  Society  of  Social 
Economics,  which  has  already  been  mentioned  as  one  of  the  propaganda 
agencies  supporting  the  commercial  insurance  companies. 


^ 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

DOCUMENTS  DEPT. 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 

Renewed  books  are  subject  to  immediate  recall. 


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